Provider Demographics
NPI:1699202770
Name:FLEITAS, IDANIA
Entity Type:Individual
Prefix:
First Name:IDANIA
Middle Name:
Last Name:FLEITAS
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 1:17255 SW 302ND ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-3334
Mailing Address - Country:US
Mailing Address - Phone:786-738-4947
Mailing Address - Fax:786-773-3394
Practice Address - Street 1:1665 W 68TH ST STE 201
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4400
Practice Address - Country:US
Practice Address - Phone:786-773-3393
Practice Address - Fax:786-773-3394
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician