Provider Demographics
NPI:1407334139
Name:COVA DE GIMENEZ, RAQUEL ANGELINA
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:ANGELINA
Last Name:COVA DE GIMENEZ
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 1:12090 NE 16TH AVE APT 111
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-6538
Mailing Address - Country:US
Mailing Address - Phone:786-366-1847
Mailing Address - Fax:
Practice Address - Street 1:12090 NE 16TH AVE APT 111
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-6538
Practice Address - Country:US
Practice Address - Phone:786-366-1847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician