Provider Demographics
NPI:1104366459
Name:BERNAZA MORALES, ETHEL
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:
Last Name:BERNAZA MORALES
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 1:10953 SW 181ST TER
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-9012
Mailing Address - Country:US
Mailing Address - Phone:786-212-1008
Mailing Address - Fax:786-334-5826
Practice Address - Street 1:10953 SW 181ST TER
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-9012
Practice Address - Country:US
Practice Address - Phone:786-212-1008
Practice Address - Fax:786-334-5826
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician