Provider Demographics
NPI:1891144606
Name:MEDEROS, ILEANA
Entity Type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:MEDEROS
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 1:12955 SW 66TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-5217
Mailing Address - Country:US
Mailing Address - Phone:786-346-9001
Mailing Address - Fax:
Practice Address - Street 1:12955 SW 66TH LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183
Practice Address - Country:US
Practice Address - Phone:786-346-9001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018158500Medicaid