Provider Demographics
NPI:1275165367
Name:BERROA, MELIDA
Entity Type:Individual
Prefix:
First Name:MELIDA
Middle Name:
Last Name:BERROA
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 1:250 NW 190TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-4002
Mailing Address - Country:US
Mailing Address - Phone:786-529-6486
Mailing Address - Fax:305-437-7675
Practice Address - Street 1:250 NW 190TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-4002
Practice Address - Country:US
Practice Address - Phone:786-529-6486
Practice Address - Fax:305-437-7675
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103K00000X
FLSW17036104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL84-4342759Medicaid