Provider Demographics
NPI:1407505456
Name:VAN BRAKLE, YALIT
Entity Type:Individual
Prefix:MRS
First Name:YALIT
Middle Name:
Last Name:VAN BRAKLE
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 1:7480 SW 152ND AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2398
Mailing Address - Country:US
Mailing Address - Phone:786-394-3437
Mailing Address - Fax:
Practice Address - Street 1:7480 SW 152ND AVE APT 3
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-2398
Practice Address - Country:US
Practice Address - Phone:786-394-3437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-119447106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV-516-960-84-633-0Medicaid