Provider Demographics
NPI:1801631866
Name:FUENTES FIGUEREDO, GRETEL
Entity type:Individual
Prefix:
First Name:GRETEL
Middle Name:
Last Name:FUENTES FIGUEREDO
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 1:1100 NW 26TH AVENUE RD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-3138
Mailing Address - Country:US
Mailing Address - Phone:786-793-5412
Mailing Address - Fax:
Practice Address - Street 1:1100 NW 26TH AVENUE RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-3138
Practice Address - Country:US
Practice Address - Phone:786-793-5412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1080551106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician