Provider Demographics
NPI:1568115350
Name:BACALLAO MENDEZ, YASMIN
Entity Type:Individual
Prefix:
First Name:YASMIN
Middle Name:
Last Name:BACALLAO MENDEZ
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 1:4111 NW 37TH AVE LOT D426
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-4242
Mailing Address - Country:US
Mailing Address - Phone:786-915-9453
Mailing Address - Fax:
Practice Address - Street 1:4111 NW 37TH AVE LOT D426
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-4242
Practice Address - Country:US
Practice Address - Phone:786-915-9453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-154916106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty