Provider Demographics
NPI:1093403024
Name:REY RODRIGUEZ, GRETTER ANAUDINA
Entity Type:Individual
Prefix:
First Name:GRETTER
Middle Name:ANAUDINA
Last Name:REY RODRIGUEZ
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 1:525 NW 27TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-3039
Mailing Address - Country:US
Mailing Address - Phone:305-200-5073
Mailing Address - Fax:
Practice Address - Street 1:525 NW 27TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-3039
Practice Address - Country:US
Practice Address - Phone:305-200-5073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-23-267396106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician