Provider Demographics
NPI:1801331038
Name:BOULLOSA, YADMILA
Entity type:Individual
Prefix:
First Name:YADMILA
Middle Name:
Last Name:BOULLOSA
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 1:2331 NW 96TH TER APT 17B
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3043
Mailing Address - Country:US
Mailing Address - Phone:786-393-0361
Mailing Address - Fax:
Practice Address - Street 1:1280 NW 79TH ST
Practice Address - Street 2:303
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33147
Practice Address - Country:US
Practice Address - Phone:305-877-3590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-26
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician