Provider Demographics
NPI:1912623695
Name:SERPA, RACHELY TERESA
Entity Type:Individual
Prefix:
First Name:RACHELY
Middle Name:TERESA
Last Name:SERPA
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 1:9400 W FLAGLER ST APT 113
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-2025
Mailing Address - Country:US
Mailing Address - Phone:786-484-5522
Mailing Address - Fax:
Practice Address - Street 1:9400 W FLAGLER ST APT 113
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-2025
Practice Address - Country:US
Practice Address - Phone:786-484-5522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-14
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20128867103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20128867Medicaid