Basic Information
| Provider Information | |||||||||
| NPI: | 1376986869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGUIRREGAVIRIA | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10850 S US HIGHWAY 1 STE 2 | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349526407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724630444 | ||||||||
| FaxNumber: | 7726759100 | ||||||||
| Practice Location | |||||||||
| Address1: | 10850 S US HIGHWAY 1 STE 2 | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349526407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724630444 | ||||||||
| FaxNumber: | 7726759100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2013 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-10-3982 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 106E00000X | N | 193200000X MULTI-SPECIALTY GROUP |
No ID Information.