Provider Demographics
NPI:1568069458
Name:TALAVERA, OLGA LIDIA
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:LIDIA
Last Name:TALAVERA
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 1:10689 N KENDALL DR STE 309
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1525
Mailing Address - Country:US
Mailing Address - Phone:786-536-7470
Mailing Address - Fax:786-536-7951
Practice Address - Street 1:10689 N KENDALL DR STE 309
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1525
Practice Address - Country:US
Practice Address - Phone:786-536-7470
Practice Address - Fax:786-536-7951
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT20-125265106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108034000Medicaid
FLRBT-20-125265Medicaid