Provider Demographics
NPI:1497269021
Name:SIS MOREIRA, DALLAMY
Entity Type:Individual
Prefix:
First Name:DALLAMY
Middle Name:
Last Name:SIS MOREIRA
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 1:746 SW 2ND ST APT 5
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-2342
Mailing Address - Country:US
Mailing Address - Phone:786-805-7832
Mailing Address - Fax:
Practice Address - Street 1:14750 SW 26TH ST STE 114
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-5934
Practice Address - Country:US
Practice Address - Phone:786-536-9441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-71211106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023005400Medicaid