Provider Demographics
NPI:1144805706
Name:OLIVERA REQUENA, ANGEL WILVER
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:WILVER
Last Name:OLIVERA REQUENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 W 12TH ST APT 7A
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-2984
Mailing Address - Country:US
Mailing Address - Phone:832-891-4137
Mailing Address - Fax:
Practice Address - Street 1:495 W 12TH ST APT 7A
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-2984
Practice Address - Country:US
Practice Address - Phone:832-891-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-148251106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician