Provider Demographics
NPI:1588316202
Name:MORENO VALDIVIA, ANDY
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:MORENO VALDIVIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10732 SW 225TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-6513
Mailing Address - Country:US
Mailing Address - Phone:786-230-6701
Mailing Address - Fax:
Practice Address - Street 1:10732 SW 225TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33170-6513
Practice Address - Country:US
Practice Address - Phone:786-230-6701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-70700106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021835700Medicaid