Provider Demographics
NPI:1700632205
Name:MENA ZALDIVAR, LUISMEL
Entity Type:Individual
Prefix:
First Name:LUISMEL
Middle Name:
Last Name:MENA ZALDIVAR
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 1:791 SW 64TH AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-3758
Mailing Address - Country:US
Mailing Address - Phone:305-963-9791
Mailing Address - Fax:
Practice Address - Street 1:7900 OAK LN STE 400
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-6001
Practice Address - Country:US
Practice Address - Phone:786-622-5743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-339144106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician