Provider Demographics
NPI:1639647639
Name:ALFONSO PENATE, MAYBELIS
Entity Type:Individual
Prefix:MS
First Name:MAYBELIS
Middle Name:
Last Name:ALFONSO PENATE
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 1:8255 ABBOTT AVE APT 406
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33141-5231
Mailing Address - Country:US
Mailing Address - Phone:305-967-9109
Mailing Address - Fax:
Practice Address - Street 1:8255 ABBOTT AVE APT 406
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33141-5231
Practice Address - Country:US
Practice Address - Phone:305-967-9109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-57735106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician