Basic Information
Provider Information | |||||||||
NPI: | 1851658272 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEDRAZA | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PEDRAZA | ||||||||
OtherFirstName: | RICK | ||||||||
OtherMiddleName: | JOSEPH | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: | JR. | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 310 RACHELLE AVE | ||||||||
Address2: | # 737 | ||||||||
City: | SANFORD | ||||||||
State: | FL | ||||||||
PostalCode: | 327717968 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4075067785 | ||||||||
FaxNumber: | 4078946010 | ||||||||
Practice Location | |||||||||
Address1: | 2479 ALOMA AVE | ||||||||
Address2: |   | ||||||||
City: | WINTER PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 327922541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4076576692 | ||||||||
FaxNumber: | 4078946010 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2012 | ||||||||
LastUpdateDate: | 04/23/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.