Provider Demographics
NPI:1891434072
Name:PRIETO, LAURA DEL CARMEN (CBHCM104204)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:DEL CARMEN
Last Name:PRIETO
Suffix:
Gender:F
Credentials:CBHCM104204
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2951 W 80TH ST APT 204
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-3892
Mailing Address - Country:US
Mailing Address - Phone:786-285-6139
Mailing Address - Fax:
Practice Address - Street 1:5590 W 20TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-7062
Practice Address - Country:US
Practice Address - Phone:305-825-4320
Practice Address - Fax:305-825-8117
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM104204104100000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110111300Medicaid