Provider Demographics
NPI:1417403726
Name:AGREDANO, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:AGREDANO
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:PO BOX 852
Mailing Address - Street 2:
Mailing Address - City:ORACLE
Mailing Address - State:AZ
Mailing Address - Zip Code:85623-0852
Mailing Address - Country:US
Mailing Address - Phone:520-260-5390
Mailing Address - Fax:
Practice Address - Street 1:500 FAIRWAY DR STE 102
Practice Address - Street 2:
Practice Address - City:DEERFIELD BCH
Practice Address - State:FL
Practice Address - Zip Code:33441-1817
Practice Address - Country:US
Practice Address - Phone:520-661-8559
Practice Address - Fax:954-342-0273
Is Sole Proprietor?:No
Enumeration Date:2016-08-27
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103K00000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst