Provider Demographics
NPI:1578390118
Name:TAVERA, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:TAVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11208 SW 249TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6053
Mailing Address - Country:US
Mailing Address - Phone:619-372-5458
Mailing Address - Fax:
Practice Address - Street 1:11208 SW 249TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-6053
Practice Address - Country:US
Practice Address - Phone:619-372-5458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician