Provider Demographics
NPI:1356051023
Name:MENJIVAR CALLES, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:MENJIVAR CALLES
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 1:14900 SW 283RD ST APT 203
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-1577
Mailing Address - Country:US
Mailing Address - Phone:786-716-4059
Mailing Address - Fax:
Practice Address - Street 1:14900 SW 283RD ST APT 203
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-1577
Practice Address - Country:US
Practice Address - Phone:786-716-4059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-02
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-245447106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician