Provider Demographics
NPI:1134969009
Name:BORROTO CARABALLO, IDELSYS B
Entity type:Individual
Prefix:
First Name:IDELSYS
Middle Name:B
Last Name:BORROTO CARABALLO
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 1:11312 SW 132ND CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-7900
Mailing Address - Country:US
Mailing Address - Phone:786-238-6898
Mailing Address - Fax:
Practice Address - Street 1:11312 SW 132ND CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-7900
Practice Address - Country:US
Practice Address - Phone:786-238-6898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-346077106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty