Provider Demographics
NPI:1790400745
Name:URGELLES, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:URGELLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15203 SW 141ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-5019
Mailing Address - Country:US
Mailing Address - Phone:305-497-0929
Mailing Address - Fax:
Practice Address - Street 1:11276 SW 232ND ST
Practice Address - Street 2:
Practice Address - City:GOULDS
Practice Address - State:FL
Practice Address - Zip Code:33170-7505
Practice Address - Country:US
Practice Address - Phone:305-912-8399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLU624-540-99-135-0106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty