Provider Demographics
NPI:1851154934
Name:PUPO MENDEZ, MAITE
Entity Type:Individual
Prefix:
First Name:MAITE
Middle Name:
Last Name:PUPO MENDEZ
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 1:3620 COLONIAL BLVD STE 180
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1076
Mailing Address - Country:US
Mailing Address - Phone:239-800-9289
Mailing Address - Fax:
Practice Address - Street 1:3620 COLONIAL BLVD STE 180
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1076
Practice Address - Country:US
Practice Address - Phone:239-800-9289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT24-323268106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician