Provider Demographics
NPI:1639692395
Name:TRAVIESO QUINTANA, GLADYS
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:TRAVIESO QUINTANA
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 1:3790 W 6TH LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4215
Mailing Address - Country:US
Mailing Address - Phone:786-237-7096
Mailing Address - Fax:
Practice Address - Street 1:3790 W 6TH LN
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4215
Practice Address - Country:US
Practice Address - Phone:786-237-7096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-118371106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106662800Medicaid