Provider Demographics
NPI:1427820992
Name:PUPO, IMANDRA T (RBT)
Entity type:Individual
Prefix:
First Name:IMANDRA
Middle Name:T
Last Name:PUPO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 NW 24TH ST FRNT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-7212
Mailing Address - Country:US
Mailing Address - Phone:305-316-3258
Mailing Address - Fax:
Practice Address - Street 1:2624 NW 24TH ST FRNT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-7212
Practice Address - Country:US
Practice Address - Phone:305-316-3258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-306920106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician