Provider Demographics
NPI:1912781402
Name:VILLAFANA FERNANDEZ, RAIDEL ALEJANDRO
Entity Type:Individual
Prefix:
First Name:RAIDEL
Middle Name:ALEJANDRO
Last Name:VILLAFANA FERNANDEZ
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 1:6870 W 7TH AVE APT 34B
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4859
Mailing Address - Country:US
Mailing Address - Phone:786-580-9883
Mailing Address - Fax:
Practice Address - Street 1:6870 W 7TH AVE APT 34B
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4859
Practice Address - Country:US
Practice Address - Phone:786-580-9883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-119903106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician