Provider Demographics
NPI:1497242028
Name:REVES OQUENDO, DELAINE
Entity Type:Individual
Prefix:
First Name:DELAINE
Middle Name:
Last Name:REVES OQUENDO
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 1:5440 W 21ST CT APT 302
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-2061
Mailing Address - Country:US
Mailing Address - Phone:305-879-2677
Mailing Address - Fax:
Practice Address - Street 1:5440 W 21ST CT APT 302
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-2061
Practice Address - Country:US
Practice Address - Phone:305-879-2677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-20-10839106E00000X
FL106S00000X
FL1-21-49747103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022143000Medicaid