Provider Demographics
NPI:1982292462
Name:IDARRAGA, LAURA XILENA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:XILENA
Last Name:IDARRAGA
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 1:207 DENNISON RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4576
Mailing Address - Country:US
Mailing Address - Phone:813-510-7415
Mailing Address - Fax:
Practice Address - Street 1:207 DENNISON RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4576
Practice Address - Country:US
Practice Address - Phone:813-510-7415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLI362539998480103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist