Provider Demographics
NPI:1649027210
Name:RODRIGUEZ ZARDON, MAYDALIS D
Entity type:Individual
Prefix:
First Name:MAYDALIS
Middle Name:D
Last Name:RODRIGUEZ ZARDON
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 1:467 MARTIGUES DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-3412
Mailing Address - Country:US
Mailing Address - Phone:305-391-0053
Mailing Address - Fax:
Practice Address - Street 1:3501 W VINE ST STE 124
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4660
Practice Address - Country:US
Practice Address - Phone:407-483-3074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty