Provider Demographics
NPI:1336815018
Name:COSTA DE LA TORRE, MAYTE MERCEDES
Entity Type:Individual
Prefix:
First Name:MAYTE
Middle Name:MERCEDES
Last Name:COSTA DE LA TORRE
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 1:34240 SW 187TH AVE UNIT 104
Mailing Address - Street 2:
Mailing Address - City:FLORIDA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33034-2026
Mailing Address - Country:US
Mailing Address - Phone:786-612-9793
Mailing Address - Fax:855-905-4839
Practice Address - Street 1:34240 SW 187TH AVE UNIT 104
Practice Address - Street 2:
Practice Address - City:FLORIDA CITY
Practice Address - State:FL
Practice Address - Zip Code:33034-2026
Practice Address - Country:US
Practice Address - Phone:786-612-9793
Practice Address - Fax:855-905-4839
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-136775106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician