Provider Demographics
NPI:1528594538
Name:PRIDA SIMANCA, IVONNE
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:
Last Name:PRIDA SIMANCA
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 1:11735 SW 186TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-3268
Mailing Address - Country:US
Mailing Address - Phone:786-253-6849
Mailing Address - Fax:
Practice Address - Street 1:11735 SW 186TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-3268
Practice Address - Country:US
Practice Address - Phone:786-253-6849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-56914106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician