Provider Demographics
NPI:1316659063
Name:ANGIE BEHAVIORAL CORP
Entity type:Organization
Organization Name:ANGIE BEHAVIORAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAYDELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LA ROSA LLERENA
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:305-316-0458
Mailing Address - Street 1:7390 W 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-5349
Mailing Address - Country:US
Mailing Address - Phone:305-316-0458
Mailing Address - Fax:
Practice Address - Street 1:11117 W OKEECHOBEE RD STE 123
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-4210
Practice Address - Country:US
Practice Address - Phone:305-316-0458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty