Provider Demographics
NPI:1194845644
Name:FELICIANO, JUAN RICARDO
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:RICARDO
Last Name:FELICIANO
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JUAN
Other - Middle Name:RICARDO
Other - Last Name:FELICIANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:3002 HAMBLIN WAY
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3424
Mailing Address - Country:US
Mailing Address - Phone:561-685-0490
Mailing Address - Fax:
Practice Address - Street 1:11120 S CROWN WAY STE 1
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-790-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7464101YM0800X
FLPY8938103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist