Provider Demographics
NPI:1811486095
Name:CARABALLO, MISLEIDY
Entity type:Individual
Prefix:
First Name:MISLEIDY
Middle Name:
Last Name:CARABALLO
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 1:26554 SW 124TH CT
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-7915
Mailing Address - Country:US
Mailing Address - Phone:786-217-3874
Mailing Address - Fax:
Practice Address - Street 1:654 NE 9TH PL
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4934
Practice Address - Country:US
Practice Address - Phone:305-248-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-121250106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021063600Medicaid