Provider Demographics
NPI:1649773474
Name:AGREDO, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:AGREDO
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 1:2925 NW 130TH AVE APT 329
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-3075
Mailing Address - Country:US
Mailing Address - Phone:954-937-9559
Mailing Address - Fax:
Practice Address - Street 1:2925 NW 130TH AVE APT 329
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-3075
Practice Address - Country:US
Practice Address - Phone:954-937-9559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-18
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI46532355S0801X
FLA263540935500103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024317100Medicaid