Provider Demographics
NPI:1912628793
Name:MOMPELAS, THARALEE
Entity Type:Individual
Prefix:
First Name:THARALEE
Middle Name:
Last Name:MOMPELAS
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 1:6109 NW 41ST DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-3216
Mailing Address - Country:US
Mailing Address - Phone:954-394-2588
Mailing Address - Fax:
Practice Address - Street 1:13650 NW 8TH ST STE 109
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33325-6239
Practice Address - Country:US
Practice Address - Phone:888-490-5514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-233710106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2208128Medicaid