Provider Demographics
NPI:1235652470
Name:DE LA TORRE, IMILSY
Entity Type:Individual
Prefix:
First Name:IMILSY
Middle Name:
Last Name:DE LA TORRE
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 1:12239 SW 14TH LN APT 3306
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2843
Mailing Address - Country:US
Mailing Address - Phone:305-794-8614
Mailing Address - Fax:
Practice Address - Street 1:12239 SW 14TH LN APT 3306
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-2843
Practice Address - Country:US
Practice Address - Phone:305-794-8614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-18-65270106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician