Provider Demographics
NPI:1407477441
Name:HERRERA CONSUEGRA, IVET
Entity Type:Individual
Prefix:
First Name:IVET
Middle Name:
Last Name:HERRERA CONSUEGRA
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 1:4508 EDEN ROCK RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-7320
Mailing Address - Country:US
Mailing Address - Phone:813-296-9333
Mailing Address - Fax:
Practice Address - Street 1:4508 EDEN ROCK RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-7320
Practice Address - Country:US
Practice Address - Phone:813-296-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician