Provider Demographics
NPI:1114515798
Name:ELIZONDO PENALVER, DAYMI
Entity Type:Individual
Prefix:MS
First Name:DAYMI
Middle Name:
Last Name:ELIZONDO PENALVER
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 1:12354 SW 259TH TER
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-7072
Mailing Address - Country:US
Mailing Address - Phone:305-846-2436
Mailing Address - Fax:
Practice Address - Street 1:12354 SW 259TH TER
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-7072
Practice Address - Country:US
Practice Address - Phone:305-846-2436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT20144091106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT20144091OtherBEHAVIOR TECHNICIAN