Basic Information
| Provider Information | |||||||||
| NPI: | 1689255846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALONSO | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | LISET | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15131 SW 138TH TER | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331965627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058789783 | ||||||||
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| Practice Location | |||||||||
| Address1: | 518 SW PRIMA VISTA BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349838734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7728738811 | ||||||||
| FaxNumber: | 7728738800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2021 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.