Provider Demographics
NPI:1639222169
Name:MAYORGA, ALLISSON
Entity Type:Individual
Prefix:
First Name:ALLISSON
Middle Name:
Last Name:MAYORGA
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 1:883 NW 133RD CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2205
Mailing Address - Country:US
Mailing Address - Phone:305-498-6660
Mailing Address - Fax:
Practice Address - Street 1:2771 EXECUTIVE PARK DR
Practice Address - Street 2:CHILDREN'S CENTER FOR DEVELOPMENT & BEHAVIOR
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3642
Practice Address - Country:US
Practice Address - Phone:954-745-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X, 103TE1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Not Answered103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports