Provider Demographics
NPI:1336679562
Name:DE LA FUENTE ZABALA, MERLY
Entity Type:Individual
Prefix:
First Name:MERLY
Middle Name:
Last Name:DE LA FUENTE ZABALA
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 1:8365 SW 152ND AVE APT C-115
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-4028
Mailing Address - Country:US
Mailing Address - Phone:786-366-6145
Mailing Address - Fax:
Practice Address - Street 1:8365 SW 152ND AVE APT C-115
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-4028
Practice Address - Country:US
Practice Address - Phone:786-366-6145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL20-117081106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst