Basic Information
| Provider Information | |||||||||
| NPI: | 1710336227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENA | ||||||||
| FirstName: | YAIMA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7767 SHALIMAR ST | ||||||||
| Address2: | |||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330232425 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3440 S UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544246911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MH17340 | FL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106S00000X | FL | N | 101YM0800X | MH17340 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 017801300 | 05 | FL | MEDICAID |