Provider Demographics
NPI:1215393095
Name:BAUDANZA, ANTHONY MANUEL
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MANUEL
Last Name:BAUDANZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ANTHONY
Other - Middle Name:MANUEL
Other - Last Name:BAUDANZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CAP
Mailing Address - Street 1:4879 LOMBARD PASS DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-7467
Mailing Address - Country:US
Mailing Address - Phone:561-315-4567
Mailing Address - Fax:
Practice Address - Street 1:16110 JOG RD
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-2350
Practice Address - Country:US
Practice Address - Phone:561-265-5549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1992101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNONEOtherNONE