Provider Demographics
NPI:1437664364
Name:AZOTEA, MIA BROOKE (BCABA)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:BROOKE
Last Name:AZOTEA
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:BROOKE
Other - Last Name:CHAMBERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCABA
Mailing Address - Street 1:9000 CYPRESS GREEN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7791
Mailing Address - Country:US
Mailing Address - Phone:904-732-4343
Mailing Address - Fax:904-732-4344
Practice Address - Street 1:9000 CYPRESS GREEN DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7791
Practice Address - Country:US
Practice Address - Phone:904-732-4343
Practice Address - Fax:904-732-4344
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst