Provider Demographics
NPI:1336991165
Name:PENA MILAGROS, LIDIS MILAGROS
Entity Type:Individual
Prefix:
First Name:LIDIS
Middle Name:MILAGROS
Last Name:PENA MILAGROS
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 1:8300 NW 53RD ST STE 350
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-7712
Mailing Address - Country:US
Mailing Address - Phone:305-342-7643
Mailing Address - Fax:
Practice Address - Street 1:3560 NW 83RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33147-4509
Practice Address - Country:US
Practice Address - Phone:305-781-8153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician