Provider Demographics
NPI:1457960353
Name:CRIBEIRO GORDILLO, ODIEL
Entity Type:Individual
Prefix:
First Name:ODIEL
Middle Name:
Last Name:CRIBEIRO GORDILLO
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 1:18881 NW 88TH CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-6283
Mailing Address - Country:US
Mailing Address - Phone:786-469-0042
Mailing Address - Fax:
Practice Address - Street 1:18881 NW 88TH CT
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-6283
Practice Address - Country:US
Practice Address - Phone:786-469-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-122854106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician