Provider Demographics
NPI:1649744640
Name:HOMAR, VIVIAN LAURA
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:LAURA
Last Name:HOMAR
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 1:18501 NW 56TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-5328
Mailing Address - Country:US
Mailing Address - Phone:786-380-2951
Mailing Address - Fax:
Practice Address - Street 1:18501 NW 56TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-5328
Practice Address - Country:US
Practice Address - Phone:786-380-2951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
FL18-65388106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician