Provider Demographics
NPI:1457933004
Name:PADILLA GALIS MENENDEZ, ANTONIO H
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:H
Last Name:PADILLA GALIS MENENDEZ
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 1:4600 SW 97TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-5756
Mailing Address - Country:US
Mailing Address - Phone:786-395-8225
Mailing Address - Fax:
Practice Address - Street 1:4600 SW 97TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-5756
Practice Address - Country:US
Practice Address - Phone:786-395-8225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT21152449106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109842200Medicaid