Provider Demographics
NPI:1912669458
Name:TAVERAS, LUIS MIGUEL
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:MIGUEL
Last Name:TAVERAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3635 SW 70TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023-6610
Mailing Address - Country:US
Mailing Address - Phone:551-286-0371
Mailing Address - Fax:
Practice Address - Street 1:14359 MIRAMAR PKWY # 504
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-4134
Practice Address - Country:US
Practice Address - Phone:954-399-2637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
FLRBT-21-189174106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst