Provider Demographics
NPI:1407621303
Name:PUENTE MORATALLA, DAYLEN (RBT-22-204977)
Entity Type:Individual
Prefix:
First Name:DAYLEN
Middle Name:
Last Name:PUENTE MORATALLA
Suffix:
Gender:F
Credentials:RBT-22-204977
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11710 NW SOUTH RIVER DR APT 212
Mailing Address - Street 2:
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33178-1143
Mailing Address - Country:US
Mailing Address - Phone:786-804-7194
Mailing Address - Fax:
Practice Address - Street 1:11710 NW SOUTH RIVER DR APT 212
Practice Address - Street 2:
Practice Address - City:MEDLEY
Practice Address - State:FL
Practice Address - Zip Code:33178-1143
Practice Address - Country:US
Practice Address - Phone:786-804-7194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-204977106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician