Provider Demographics
NPI:1871091421
Name:CORREA, JORGE
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:CORREA
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 1:13225 SW 111TH TER APT 2
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-7933
Mailing Address - Country:US
Mailing Address - Phone:786-518-9905
Mailing Address - Fax:
Practice Address - Street 1:13225 SW 111TH TER APT 2
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-7933
Practice Address - Country:US
Practice Address - Phone:786-518-9905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician