Provider Demographics
NPI:1316603038
Name:CORNELIO, HEIDDY
Entity Type:Individual
Prefix:
First Name:HEIDDY
Middle Name:
Last Name:CORNELIO
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 1:5931 NW 173RD DR UNIT 10
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5107
Mailing Address - Country:US
Mailing Address - Phone:305-826-7884
Mailing Address - Fax:
Practice Address - Street 1:5931 NW 173RD DR UNIT 10
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5107
Practice Address - Country:US
Practice Address - Phone:305-826-7884
Practice Address - Fax:305-826-7884
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-121015106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician