Provider Demographics
NPI:1073265336
Name:MACHUCA HERRERA, LAURA G
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:G
Last Name:MACHUCA HERRERA
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 1:5140 CONROY RD UNIT 825
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-3741
Mailing Address - Country:US
Mailing Address - Phone:321-370-8912
Mailing Address - Fax:
Practice Address - Street 1:11602 LAKE UNDERHILL RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-4458
Practice Address - Country:US
Practice Address - Phone:407-277-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty