Provider Demographics
NPI:1629631379
Name:MENDEZ MACIAS, ELSA ROSANA
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:ROSANA
Last Name:MENDEZ MACIAS
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 1:15935 SW 112TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-4263
Mailing Address - Country:US
Mailing Address - Phone:305-216-7937
Mailing Address - Fax:
Practice Address - Street 1:15935 SW 112TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-4263
Practice Address - Country:US
Practice Address - Phone:305-216-7937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022527800Medicaid