Provider Demographics
NPI:1457818775
Name:PYFROM, MIA L (MEDICAID, MEDWAIVER)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:L
Last Name:PYFROM
Suffix:
Gender:F
Credentials:MEDICAID, MEDWAIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3243 OSPREY LN
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6492
Mailing Address - Country:US
Mailing Address - Phone:561-352-1501
Mailing Address - Fax:
Practice Address - Street 1:1818 S AUSTRALIAN AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-6452
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT1863371106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100887900Medicaid