Provider Demographics
NPI:1912475336
Name:BACALLAO MAYEDO, YUDANIA
Entity Type:Individual
Prefix:MRS
First Name:YUDANIA
Middle Name:
Last Name:BACALLAO MAYEDO
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 1:2532 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-3109
Mailing Address - Country:US
Mailing Address - Phone:786-370-3753
Mailing Address - Fax:
Practice Address - Street 1:2532 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-3109
Practice Address - Country:US
Practice Address - Phone:786-370-3753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-6672106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020297300Medicaid