Provider Demographics
NPI:1093399032
Name:DEL SOL VALLADARES, AUDREY
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:DEL SOL VALLADARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6365 SW 8TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:WEST MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-4842
Mailing Address - Country:US
Mailing Address - Phone:786-553-0305
Mailing Address - Fax:
Practice Address - Street 1:6365 SW 8TH ST APT 4
Practice Address - Street 2:
Practice Address - City:WEST MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-4842
Practice Address - Country:US
Practice Address - Phone:786-553-0305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-120817106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111635200Medicaid