Provider Demographics
NPI:1417367129
Name:PICHARDO, VIVIANA
Entity Type:Individual
Prefix:
First Name:VIVIANA
Middle Name:
Last Name:PICHARDO
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 1:3900 NW 79TH AVE
Mailing Address - Street 2:SUITE 501
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6556
Mailing Address - Country:US
Mailing Address - Phone:305-597-3861
Mailing Address - Fax:305-597-3863
Practice Address - Street 1:1639 FORUM PL STE 7
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2330
Practice Address - Country:US
Practice Address - Phone:561-712-8821
Practice Address - Fax:561-712-8070
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X, 103K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst