Provider Demographics
NPI:1295350833
Name:GARCIA REVES, MAITE
Entity type:Individual
Prefix:
First Name:MAITE
Middle Name:
Last Name:GARCIA REVES
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 1:5440 W 21ST CT APT 302
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-2061
Mailing Address - Country:US
Mailing Address - Phone:786-575-7951
Mailing Address - Fax:
Practice Address - Street 1:5440 W 21ST CT APT 302
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-2061
Practice Address - Country:US
Practice Address - Phone:786-222-5609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-122603106S00000X
FL11032659363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty