Provider Demographics
NPI:1104339175
Name:BAHAMONDE, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BAHAMONDE
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 1:15451 SW 59TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2825
Mailing Address - Country:US
Mailing Address - Phone:786-202-4291
Mailing Address - Fax:
Practice Address - Street 1:13930 SW 47TH ST STE 203
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-4400
Practice Address - Country:US
Practice Address - Phone:786-534-7127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2021-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-41962103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021057100Medicaid