Provider Demographics
NPI:1689255846
Name:ALONSO, MAYRA LISET (MD)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:LISET
Last Name:ALONSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15131 SW 138TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-5627
Mailing Address - Country:US
Mailing Address - Phone:305-878-9783
Mailing Address - Fax:
Practice Address - Street 1:518 SW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8734
Practice Address - Country:US
Practice Address - Phone:772-873-8811
Practice Address - Fax:772-873-8800
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty