Basic Information
| Provider Information | |||||||||
| NPI: | 1568944791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONGGI | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| OtherLastName: | BONGGI | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | MARIA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14114 SW 93RD LN | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331861272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862604779 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10300 SW 72ND ST STE 114 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331733038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055085580 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2018 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | 0-19-9456 | FL | N | 106S00000X | RBT-18-56956 | FL | N | 103K00000X | 1-21-55665 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.