Provider Demographics
NPI:1538689450
Name:LARRUA MENESES, VIVIAN ETHEL
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:ETHEL
Last Name:LARRUA MENESES
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 1:16915 SW 93RD AVE
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-4412
Mailing Address - Country:US
Mailing Address - Phone:786-592-2263
Mailing Address - Fax:786-272-0440
Practice Address - Street 1:16915 SW 93RD AVE
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-4412
Practice Address - Country:US
Practice Address - Phone:786-592-2263
Practice Address - Fax:786-272-0440
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician