Provider Demographics
NPI:1043964778
Name:PERSAUD, INDRANIE DONNA
Entity Type:Individual
Prefix:
First Name:INDRANIE
Middle Name:DONNA
Last Name:PERSAUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15700 COUNTY ROAD 565A
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-8995
Mailing Address - Country:US
Mailing Address - Phone:407-484-3215
Mailing Address - Fax:
Practice Address - Street 1:15700 COUNTY ROAD 565A
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-8995
Practice Address - Country:US
Practice Address - Phone:407-484-3215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105882600Medicaid