Provider Demographics
NPI:1255997912
Name:PUENTE, MADELAINE
Entity type:Individual
Prefix:
First Name:MADELAINE
Middle Name:
Last Name:PUENTE
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 1:9640 SW 152ND AVE APT 31
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-1243
Mailing Address - Country:US
Mailing Address - Phone:786-291-4532
Mailing Address - Fax:
Practice Address - Street 1:9640 SW 152ND AVE APT 31
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-1243
Practice Address - Country:US
Practice Address - Phone:786-291-4532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-18-65791106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician