Provider Demographics
NPI:1679146997
Name:TIRADO AYALA, ABRAHAM (CBHCM)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:
Last Name:TIRADO AYALA
Suffix:
Gender:M
Credentials:CBHCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 17TH TER NE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4416
Mailing Address - Country:US
Mailing Address - Phone:863-288-1635
Mailing Address - Fax:
Practice Address - Street 1:1604 17TH TER NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4416
Practice Address - Country:US
Practice Address - Phone:863-288-1635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM103930171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty