Provider Demographics
NPI:1750050852
Name:REYES PENA, MERCEDES
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:REYES PENA
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 1:589 E 52ND ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-1649
Mailing Address - Country:US
Mailing Address - Phone:786-899-9475
Mailing Address - Fax:
Practice Address - Street 1:589 E 52ND ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-1649
Practice Address - Country:US
Practice Address - Phone:786-899-9475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-132462106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108329700Medicaid