Provider Demographics
NPI:1912475898
Name:ABELLON MEDEROS, DORY AILEC
Entity Type:Individual
Prefix:
First Name:DORY
Middle Name:AILEC
Last Name:ABELLON MEDEROS
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 1:3270 NW 208 ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:33056
Mailing Address - Country:US
Mailing Address - Phone:786-757-3275
Mailing Address - Fax:
Practice Address - Street 1:3270 NW 208 ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDEN
Practice Address - State:FL
Practice Address - Zip Code:33056
Practice Address - Country:US
Practice Address - Phone:786-757-3275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019761100Medicaid