Provider Demographics
NPI:1205401163
Name:RODRIGUEZ PRADES, LILLIAM
Entity Type:Individual
Prefix:
First Name:LILLIAM
Middle Name:
Last Name:RODRIGUEZ PRADES
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 1:16254 SW 95TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-4923
Mailing Address - Country:US
Mailing Address - Phone:786-317-9964
Mailing Address - Fax:
Practice Address - Street 1:16254 SW 95TH LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-4923
Practice Address - Country:US
Practice Address - Phone:786-317-9964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-155830106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112035600Medicaid