Provider Demographics
NPI:1720590979
Name:VERA, MARIA LETICIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LETICIA
Last Name:VERA
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 1:3113 STIRLING RD STE 204
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-6547
Mailing Address - Country:US
Mailing Address - Phone:954-842-3501
Mailing Address - Fax:954-206-0906
Practice Address - Street 1:3113 STIRLING RD STE 204
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-6547
Practice Address - Country:US
Practice Address - Phone:954-842-3501
Practice Address - Fax:954-206-0906
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103T00000X
106S00000X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV656552688040OtherDRIVER LICENSE