Provider Demographics
NPI:1871001545
Name:REYES RODRIGUEZ, RAUDEL
Entity Type:Individual
Prefix:
First Name:RAUDEL
Middle Name:
Last Name:REYES RODRIGUEZ
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 1:7261 W 29TH WAY
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-5344
Mailing Address - Country:US
Mailing Address - Phone:786-714-7326
Mailing Address - Fax:
Practice Address - Street 1:7261 W 29TH WAY
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-5344
Practice Address - Country:US
Practice Address - Phone:786-714-7326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X, 106S00000X
FL1-20-43926103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty