Provider Demographics
NPI:1659883577
Name:PACHECO CACERES, MIRNA CAROLINA
Entity type:Individual
Prefix:
First Name:MIRNA
Middle Name:CAROLINA
Last Name:PACHECO CACERES
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 1:50 W 31ST ST APT 101
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5463
Mailing Address - Country:US
Mailing Address - Phone:786-803-0112
Mailing Address - Fax:
Practice Address - Street 1:5911 NW 173RD DR UNIT 11
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5122
Practice Address - Country:US
Practice Address - Phone:786-803-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL0-24-15262106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022835800Medicaid