Provider Demographics
NPI:1649901703
Name:FONTANELLA, ANAIT DIAZ
Entity type:Individual
Prefix:
First Name:ANAIT
Middle Name:DIAZ
Last Name:FONTANELLA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11341 SW 41ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-4606
Mailing Address - Country:US
Mailing Address - Phone:786-382-4374
Mailing Address - Fax:
Practice Address - Street 1:11341 SW 41ST ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-4606
Practice Address - Country:US
Practice Address - Phone:786-382-4374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL106S00000X
FLRBT-20-118065106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110404100Medicaid