Provider Demographics
NPI:1851827554
Name:BURGOS, MARISOL ALICIA (RBT)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:ALICIA
Last Name:BURGOS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NW 107TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-5923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14645 NW 77TH AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014
Practice Address - Country:US
Practice Address - Phone:754-812-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2023-08-03
Deactivation Date:2023-06-25
Deactivation Code:
Reactivation Date:2023-08-02
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst