Provider Demographics
NPI:1184420101
Name:FERNANDEZ TATO, CARLOS MIGUEL
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:MIGUEL
Last Name:FERNANDEZ TATO
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 1:15523 SW 107TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1349
Mailing Address - Country:US
Mailing Address - Phone:786-817-5303
Mailing Address - Fax:
Practice Address - Street 1:15523 SW 107TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-1349
Practice Address - Country:US
Practice Address - Phone:786-817-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
FLRBT-25-413496106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician