Provider Demographics
NPI:1831782010
Name:CAO VENEGAS, GRETHER
Entity type:Individual
Prefix:
First Name:GRETHER
Middle Name:
Last Name:CAO VENEGAS
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 1:19800 SW 180TH AVE LOT 416
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33187-2657
Mailing Address - Country:US
Mailing Address - Phone:786-399-6505
Mailing Address - Fax:
Practice Address - Street 1:19800 SW 180TH AVE LOT 416
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33187-2657
Practice Address - Country:US
Practice Address - Phone:786-399-6505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-139156106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-139156OtherBACB