Provider Demographics
NPI:1114538105
Name:GINIEBRA QUEVEDO, YUSELIS (BEHAVIOR TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:YUSELIS
Middle Name:
Last Name:GINIEBRA QUEVEDO
Suffix:
Gender:F
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12365 SW 18TH ST APT 211
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-1542
Mailing Address - Country:US
Mailing Address - Phone:786-461-4662
Mailing Address - Fax:
Practice Address - Street 1:8180 NW 36TH ST STE 100Q
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6625
Practice Address - Country:US
Practice Address - Phone:305-448-8636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB581060106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician