Provider Demographics
NPI:1508513649
Name:FERNANDINIS SORIS, MAURO J
Entity Type:Individual
Prefix:
First Name:MAURO
Middle Name:J
Last Name:FERNANDINIS SORIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11025 SW 155TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1204
Mailing Address - Country:US
Mailing Address - Phone:786-399-9814
Mailing Address - Fax:
Practice Address - Street 1:11025 SW 155TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-1204
Practice Address - Country:US
Practice Address - Phone:786-399-9814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-193355106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician