Basic Information
| Provider Information | |||||||||
| NPI: | 1417403726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGREDANO | ||||||||
| FirstName: | JOSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 852 | ||||||||
| Address2: | |||||||||
| City: | ORACLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856230852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202605390 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 FAIRWAY DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | DEERFIELD BCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334411817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206618559 | ||||||||
| FaxNumber: | 9543420273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2016 | ||||||||
| LastUpdateDate: | 08/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 103K00000X | AZ | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.