Provider Demographics
NPI:1932718178
Name:MYRTIL, CORALIZ
Entity Type:Individual
Prefix:
First Name:CORALIZ
Middle Name:
Last Name:MYRTIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CORALIZ
Other - Middle Name:
Other - Last Name:MYRTIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1951 NW 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1951 NW 7TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1104
Practice Address - Country:US
Practice Address - Phone:407-232-0347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH18070101YM0800X
FL19605101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health