Provider Demographics
NPI:1306392170
Name:MONTEAGUDO, MARTA SUSANA
Entity Type:Individual
Prefix:
First Name:MARTA SUSANA
Middle Name:
Last Name:MONTEAGUDO
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 1:6215 W 20TH AVE APT 414
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6215 W 20TH AVE APT 414
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6057
Practice Address - Country:US
Practice Address - Phone:786-740-1517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician