Provider Demographics
NPI:1235641184
Name:HEREDIA, MIGUEL
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:HEREDIA
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 1:6071 NW 198TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14411 COMMERCE WAY STE 310
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-1532
Practice Address - Country:US
Practice Address - Phone:305-827-2822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician