Provider Demographics
NPI:1306279666
Name:ALONZO, TERESITA
Entity type:Individual
Prefix:
First Name:TERESITA
Middle Name:
Last Name:ALONZO
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 1:6632 TRAILRIDE N
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-3278
Mailing Address - Country:US
Mailing Address - Phone:850-626-4897
Mailing Address - Fax:
Practice Address - Street 1:6632 TRAILRIDE N
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-3278
Practice Address - Country:US
Practice Address - Phone:850-626-4897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6905409320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL141427500Medicaid