Provider Demographics
NPI:1033867858
Name:MESA, ANDY V
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:V
Last Name:MESA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10017 W OKEECHOBEE RD APT 103
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33016-3137
Mailing Address - Country:US
Mailing Address - Phone:786-307-5198
Mailing Address - Fax:
Practice Address - Street 1:14221 SW 120TH ST STE 227
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4225
Practice Address - Country:US
Practice Address - Phone:305-300-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT21184567106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician