Provider Demographics
NPI:1619566437
Name:REYES CAMPOS, MADELAYNE
Entity Type:Individual
Prefix:
First Name:MADELAYNE
Middle Name:
Last Name:REYES CAMPOS
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 1:10367 N KENDALL DR APT E2
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1633
Mailing Address - Country:US
Mailing Address - Phone:305-798-8473
Mailing Address - Fax:
Practice Address - Street 1:10367 N KENDALL DR APT E2
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1633
Practice Address - Country:US
Practice Address - Phone:305-798-8473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-143883106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician