Provider Demographics
NPI:1518735372
Name:SOSA FUNDORA, MAELIS DE LOS ANGELES
Entity Type:Individual
Prefix:
First Name:MAELIS
Middle Name:DE LOS ANGELES
Last Name:SOSA FUNDORA
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 1:17137 SW 112TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-3906
Mailing Address - Country:US
Mailing Address - Phone:786-727-3918
Mailing Address - Fax:
Practice Address - Street 1:17137 SW 112TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-3906
Practice Address - Country:US
Practice Address - Phone:786-727-3918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-307623106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician