Provider Demographics
NPI:1467825216
Name:VASALLO, MIDALYS
Entity Type:Individual
Prefix:
First Name:MIDALYS
Middle Name:
Last Name:VASALLO
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 1:3900 NW 79TH AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6556
Practice Address - Country:US
Practice Address - Phone:305-597-3861
Practice Address - Fax:305-597-3863
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst