Provider Demographics
NPI:1093437931
Name:BRAVO AGUILERA, LIDIBETH
Entity Type:Individual
Prefix:
First Name:LIDIBETH
Middle Name:
Last Name:BRAVO AGUILERA
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 1:11409 SW 45TH CT UNIT 110
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-7897
Mailing Address - Country:US
Mailing Address - Phone:786-835-8836
Mailing Address - Fax:
Practice Address - Street 1:7875 NW 12TH ST STE 110
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1815
Practice Address - Country:US
Practice Address - Phone:786-835-8836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22-231922106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician