Provider Demographics
NPI:1356012793
Name:BOUTROS, SURY MARIA
Entity Type:Individual
Prefix:
First Name:SURY
Middle Name:MARIA
Last Name:BOUTROS
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 1:13300 SW 47TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-5266
Mailing Address - Country:US
Mailing Address - Phone:979-422-8024
Mailing Address - Fax:
Practice Address - Street 1:13300 SW 47TH ST APT 202
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-5266
Practice Address - Country:US
Practice Address - Phone:979-422-8024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-108059106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician