Provider Demographics
NPI:1568172690
Name:DOS SANTOS MENDOZA, ANGIE ESTEFANY
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:ESTEFANY
Last Name:DOS SANTOS MENDOZA
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 1:20504 SW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5030
Mailing Address - Country:US
Mailing Address - Phone:954-268-7001
Mailing Address - Fax:
Practice Address - Street 1:20504 SW 5TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-5030
Practice Address - Country:US
Practice Address - Phone:954-268-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-30
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-230030106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician