Provider Demographics
NPI:1356101836
Name:LAFORTUNE, MAEDY
Entity type:Individual
Prefix:
First Name:MAEDY
Middle Name:
Last Name:LAFORTUNE
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 1:5961 N FALLS CIRCLE DR APT 314
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-6817
Mailing Address - Country:US
Mailing Address - Phone:754-239-0440
Mailing Address - Fax:
Practice Address - Street 1:5961 N FALLS CIRCLE DR APT 314
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33319-6817
Practice Address - Country:US
Practice Address - Phone:754-239-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL163-540-94-131-0106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician