Provider Demographics
NPI:1629464573
Name:DEDIC, IMRENA (BCABA)
Entity Type:Individual
Prefix:MISS
First Name:IMRENA
Middle Name:
Last Name:DEDIC
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 110TH AVE N APT 1010
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-3155
Mailing Address - Country:US
Mailing Address - Phone:904-338-2368
Mailing Address - Fax:305-846-9711
Practice Address - Street 1:5100 78TH AVE N STE 6
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-2407
Practice Address - Country:US
Practice Address - Phone:727-289-9626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-23-14460106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst