Provider Demographics
NPI:1275234098
Name:MARRERO PENATE, ANDY
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:MARRERO PENATE
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 1:7200 SAINT ANDREWS RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-1315
Mailing Address - Country:US
Mailing Address - Phone:561-891-3089
Mailing Address - Fax:
Practice Address - Street 1:1521 FOREST HILL BLVD STE 3
Practice Address - Street 2:
Practice Address - City:LAKE CLARKE SHORES
Practice Address - State:FL
Practice Address - Zip Code:33406-6031
Practice Address - Country:US
Practice Address - Phone:561-444-2814
Practice Address - Fax:561-444-2458
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-234017106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician