Provider Demographics
NPI:1972145514
Name:BALTODANO, FERNANDO
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:BALTODANO
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 1:25811 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5528
Mailing Address - Country:US
Mailing Address - Phone:786-447-2402
Mailing Address - Fax:
Practice Address - Street 1:25811 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-5528
Practice Address - Country:US
Practice Address - Phone:786-447-2402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-24-73288103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst