Provider Demographics
NPI:1952044026
Name:CIVIL CABALLERO, MIRIAM Y
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:Y
Last Name:CIVIL CABALLERO
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 1:2715 W PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2912
Mailing Address - Country:US
Mailing Address - Phone:832-935-1164
Mailing Address - Fax:
Practice Address - Street 1:2715 W PALMETTO ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-2912
Practice Address - Country:US
Practice Address - Phone:832-935-1164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-207724106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty