Provider Demographics
NPI:1104045509
Name:MADERAL, LUIS R (MA,MDIV)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:R
Last Name:MADERAL
Suffix:
Gender:M
Credentials:MA,MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6750 SW 104TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-3252
Mailing Address - Country:US
Mailing Address - Phone:305-221-5366
Mailing Address - Fax:305-667-9496
Practice Address - Street 1:8766 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-3201
Practice Address - Country:US
Practice Address - Phone:305-221-5366
Practice Address - Fax:305-667-9496
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT0001134106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist