Provider Demographics
NPI:1962164178
Name:FRAGA PEREZ, AMARILY
Entity type:Individual
Prefix:
First Name:AMARILY
Middle Name:
Last Name:FRAGA PEREZ
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 1:2305 CARROLL GROVE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-6522
Mailing Address - Country:US
Mailing Address - Phone:813-877-6900
Mailing Address - Fax:
Practice Address - Street 1:2305 CARROLL GROVE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6522
Practice Address - Country:US
Practice Address - Phone:813-506-1701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT24324167106S00000X
FLMA95922225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBACB776569Medicaid