Provider Demographics
NPI:1265222871
Name:PAULINO-OVALLES, LIA
Entity type:Individual
Prefix:
First Name:LIA
Middle Name:
Last Name:PAULINO-OVALLES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 S UNIVERSITY DR STE 204D
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3811
Mailing Address - Country:US
Mailing Address - Phone:800-484-6803
Mailing Address - Fax:954-595-2728
Practice Address - Street 1:4900 S UNIVERSITY DR
Practice Address - Street 2:204-D
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-3811
Practice Address - Country:US
Practice Address - Phone:800-484-6803
Practice Address - Fax:954-595-2728
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-07
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLP451-525-05-622-0106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty