Provider Demographics
NPI:1265068621
Name:CASANOLA, ODALYS
Entity type:Individual
Prefix:
First Name:ODALYS
Middle Name:
Last Name:CASANOLA
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 1:741 NW 45TH AVE APT 22
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2467
Mailing Address - Country:US
Mailing Address - Phone:786-253-5481
Mailing Address - Fax:
Practice Address - Street 1:1881 NW 123RD AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3825
Practice Address - Country:US
Practice Address - Phone:854-589-5697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-114220106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician