Provider Demographics
NPI:1659889939
Name:RUGAMA LEIVA, AMANDA LIANE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LIANE
Last Name:RUGAMA LEIVA
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 1:3801 SW 153RD CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4706
Mailing Address - Country:US
Mailing Address - Phone:305-766-3097
Mailing Address - Fax:
Practice Address - Street 1:13195 SW 134TH ST STE 201
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4585
Practice Address - Country:US
Practice Address - Phone:305-766-3097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-20
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023465900Medicaid