Provider Demographics
NPI:1598181398
Name:BERROA, JONCARLOS
Entity Type:Individual
Prefix:
First Name:JONCARLOS
Middle Name:
Last Name:BERROA
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 1:2500 NW 107TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-5925
Mailing Address - Country:US
Mailing Address - Phone:305-597-3861
Mailing Address - Fax:305-597-3863
Practice Address - Street 1:2500 NW 107TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-5925
Practice Address - Country:US
Practice Address - Phone:305-597-3861
Practice Address - Fax:305-597-3863
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program