Provider Demographics
NPI:1841405636
Name:CRITELLI DE ISOLA, MIRTA BEATRIZ (MS)
Entity type:Individual
Prefix:MRS
First Name:MIRTA
Middle Name:BEATRIZ
Last Name:CRITELLI DE ISOLA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MRS
Other - First Name:MIRTA
Other - Middle Name:
Other - Last Name:ISOLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:10442 SW 133RD PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-3449
Mailing Address - Country:US
Mailing Address - Phone:305-408-3110
Mailing Address - Fax:
Practice Address - Street 1:9380 SW 72ND ST
Practice Address - Street 2:SUITE B-120
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3276
Practice Address - Country:US
Practice Address - Phone:305-274-3738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPMH 708101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2203Medicaid