Provider Demographics
NPI:1912690827
Name:GIMENEZ, MAIDEL
Entity Type:Individual
Prefix:
First Name:MAIDEL
Middle Name:
Last Name:GIMENEZ
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 1:1087 W 23RD ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-1922
Mailing Address - Country:US
Mailing Address - Phone:786-720-3584
Mailing Address - Fax:
Practice Address - Street 1:107 NE 3RD ST STE 1
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4218
Practice Address - Country:US
Practice Address - Phone:954-256-0357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL02314358106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst