Provider Demographics
NPI:1093407793
Name:ARZAGA PERALTA, ANDREA TIANNE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:TIANNE
Last Name:ARZAGA PERALTA
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 1:2350 OWENS COMMUNITY RD
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:FL
Mailing Address - Zip Code:32462-3308
Mailing Address - Country:US
Mailing Address - Phone:808-554-5151
Mailing Address - Fax:
Practice Address - Street 1:67 HIKER ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-8826
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-273310106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician