Provider Demographics
NPI:1750127619
Name:CASTELLANOS MACIAS, IVONNE
Entity type:Individual
Prefix:
First Name:IVONNE
Middle Name:
Last Name:CASTELLANOS MACIAS
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 1:620 SW 10TH ST APT 101
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-3849
Mailing Address - Country:US
Mailing Address - Phone:786-832-3104
Mailing Address - Fax:
Practice Address - Street 1:620 SW 10TH ST APT 101
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-3849
Practice Address - Country:US
Practice Address - Phone:786-832-3104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-358084106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician