Provider Demographics
NPI:1457077836
Name:MANTILLA, YURMILA
Entity Type:Individual
Prefix:
First Name:YURMILA
Middle Name:
Last Name:MANTILLA
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 1:1086 SW COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1803
Mailing Address - Country:US
Mailing Address - Phone:786-606-7740
Mailing Address - Fax:
Practice Address - Street 1:11523 SW 169TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-3957
Practice Address - Country:US
Practice Address - Phone:786-606-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician