Provider Demographics
NPI:1720828304
Name:PAGAN HERRERA, JOHANNIS
Entity type:Individual
Prefix:
First Name:JOHANNIS
Middle Name:
Last Name:PAGAN HERRERA
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 1:28512 SEASHELL CT
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33545-4391
Mailing Address - Country:US
Mailing Address - Phone:352-347-3559
Mailing Address - Fax:
Practice Address - Street 1:13424 FORT KING RD
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-5214
Practice Address - Country:US
Practice Address - Phone:352-347-3559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-350625106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician