Provider Demographics
NPI:1164902466
Name:MAS, LIBIA
Entity Type:Individual
Prefix:
First Name:LIBIA
Middle Name:
Last Name:MAS
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 1:1001 JANN AVE
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-3325
Mailing Address - Country:US
Mailing Address - Phone:786-442-0591
Mailing Address - Fax:
Practice Address - Street 1:1001 JANN AVE
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-3325
Practice Address - Country:US
Practice Address - Phone:786-442-0591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018203900Medicaid