Provider Demographics
NPI:1457842338
Name:ORTA MATEO, AMARILIS P (CBHCM)
Entity Type:Individual
Prefix:
First Name:AMARILIS
Middle Name:P
Last Name:ORTA MATEO
Suffix:
Gender:F
Credentials:CBHCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11780 SW 18TH ST APT 209
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-1671
Mailing Address - Country:US
Mailing Address - Phone:305-606-4571
Mailing Address - Fax:
Practice Address - Street 1:1414 NW 107TH AVE STE 109
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:FL
Practice Address - Zip Code:33172-2739
Practice Address - Country:US
Practice Address - Phone:786-762-2952
Practice Address - Fax:786-762-2953
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCCM100064104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker