Provider Demographics
NPI:1114392164
Name:MOZIFORT, ANDY
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:MOZIFORT
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 1:9600 NW 25TH ST STE PH301
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-1416
Mailing Address - Country:US
Mailing Address - Phone:305-597-3861
Mailing Address - Fax:305-597-3863
Practice Address - Street 1:9600 NW 25TH ST STE PH
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172
Practice Address - Country:US
Practice Address - Phone:305-597-3861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-49564106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst