Provider Demographics
NPI:1386425726
Name:HERRERA MUJICA, ALEXANDRA L
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:L
Last Name:HERRERA MUJICA
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 1:11116 HEATHCLIFF ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-9123
Mailing Address - Country:US
Mailing Address - Phone:321-324-9627
Mailing Address - Fax:
Practice Address - Street 1:3357 W VINE ST STE 103
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4664
Practice Address - Country:US
Practice Address - Phone:407-201-6255
Practice Address - Fax:407-201-7195
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-296874106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician