Provider Demographics
NPI:1891222071
Name:CHAMIZO MERALLA, OCTAVIO (BA)
Entity Type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:
Last Name:CHAMIZO MERALLA
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20932 SW 124TH AVENUE RD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-5750
Mailing Address - Country:US
Mailing Address - Phone:786-486-7012
Mailing Address - Fax:
Practice Address - Street 1:20932 SW 124TH AVENUE RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177
Practice Address - Country:US
Practice Address - Phone:786-486-7012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst