Provider Demographics
NPI:1124709167
Name:LARREATEGUI, STEFANNY
Entity type:Individual
Prefix:
First Name:STEFANNY
Middle Name:
Last Name:LARREATEGUI
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 1:6111 NW 73RD AVE
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-6057
Mailing Address - Country:US
Mailing Address - Phone:954-709-0538
Mailing Address - Fax:
Practice Address - Street 1:4117 N PINE ISLAND RD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6005
Practice Address - Country:US
Practice Address - Phone:954-709-0538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB880050106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty