Provider Demographics
NPI:1295350155
Name:SORIA VIDAL, CARLOS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:SORIA VIDAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 NE 166TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-3880
Mailing Address - Country:US
Mailing Address - Phone:786-328-7784
Mailing Address - Fax:
Practice Address - Street 1:3660 NE 166TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-3880
Practice Address - Country:US
Practice Address - Phone:786-328-7784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-121101106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician