Basic Information
| Provider Information | |||||||||
| NPI: | 1649726753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIRETTA | ||||||||
| FirstName: | MIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7108 S KANNER HWY | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349977462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2814 WOODCLIFF CIR SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495063155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2016 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | N | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.