Provider Demographics
NPI:1164074720
Name:FERNANDEZ DE LA VEGA, MAYLIN
Entity Type:Individual
Prefix:
First Name:MAYLIN
Middle Name:
Last Name:FERNANDEZ DE LA VEGA
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 1:359 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:359 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33138-2746
Practice Address - Country:US
Practice Address - Phone:786-307-3134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-14
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty