Provider Demographics
NPI:1144793522
Name:SOTOLONGO, NIURKA (B/A)
Entity Type:Individual
Prefix:
First Name:NIURKA
Middle Name:
Last Name:SOTOLONGO
Suffix:
Gender:F
Credentials:B/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 SW 126TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-1433
Mailing Address - Country:US
Mailing Address - Phone:786-298-3321
Mailing Address - Fax:
Practice Address - Street 1:11401 SW 40TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3372
Practice Address - Country:US
Practice Address - Phone:786-580-4609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL022391600103K00000X
FLRBT20121863106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022391600Medicaid