Provider Demographics
NPI:1477370666
Name:FUSTER MAQUEIRA, ODALYS
Entity type:Individual
Prefix:
First Name:ODALYS
Middle Name:
Last Name:FUSTER MAQUEIRA
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 1:5681 NW WHITECAP RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3620
Mailing Address - Country:US
Mailing Address - Phone:305-721-7697
Mailing Address - Fax:
Practice Address - Street 1:5681 NW WHITECAP RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-3620
Practice Address - Country:US
Practice Address - Phone:305-721-7697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-371499106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician