Provider Demographics
NPI:1407451909
Name:PATINO, MIRIAM OLGA
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:OLGA
Last Name:PATINO
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 1:1289 SE 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-7044
Mailing Address - Country:US
Mailing Address - Phone:954-249-1408
Mailing Address - Fax:
Practice Address - Street 1:1289 SE 9TH AVE
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-7044
Practice Address - Country:US
Practice Address - Phone:954-249-1408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician