Provider Demographics
NPI:1174233654
Name:PEGUERO VELAZQUEZ, MARIA CARLA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:CARLA
Last Name:PEGUERO VELAZQUEZ
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 1:1351 W 38TH PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4747
Mailing Address - Country:US
Mailing Address - Phone:786-395-5748
Mailing Address - Fax:
Practice Address - Street 1:1351 W 38TH PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4747
Practice Address - Country:US
Practice Address - Phone:786-395-5748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-25
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-242925106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116496800Medicaid