Provider Demographics
NPI:1538656632
Name:FALLAS, ANGIE YESENIA
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:YESENIA
Last Name:FALLAS
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 1:6789 SW 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-5528
Mailing Address - Country:US
Mailing Address - Phone:786-606-9074
Mailing Address - Fax:
Practice Address - Street 1:11401 SW 40TH ST STE 309
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3339
Practice Address - Country:US
Practice Address - Phone:786-624-1669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022684600Medicaid