Provider Demographics
NPI:1487205290
Name:FUENTES VAZQUEZ, MERCEDES M
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:M
Last Name:FUENTES VAZQUEZ
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 1:1365 W 28TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-1036
Mailing Address - Country:US
Mailing Address - Phone:786-346-9383
Mailing Address - Fax:
Practice Address - Street 1:1365 W 28TH ST APT 3NA
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-1036
Practice Address - Country:US
Practice Address - Phone:786-346-9383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-23-14956106E00000X
FLRBT-19-99125106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician