Provider Demographics
NPI:1740912245
Name:SEPULVEDA-ROMERO, ILIANA (MA)
Entity type:Individual
Prefix:
First Name:ILIANA
Middle Name:
Last Name:SEPULVEDA-ROMERO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6444 WILEY ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33023-1765
Mailing Address - Country:US
Mailing Address - Phone:754-256-1156
Mailing Address - Fax:
Practice Address - Street 1:6444 WILEY ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33023-1765
Practice Address - Country:US
Practice Address - Phone:754-256-1156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1978Medicaid