Provider Demographics
NPI:1851349138
Name:BAGARIA, BERTHA OFELIA (PHD)
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:OFELIA
Last Name:BAGARIA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PONCE DE LEON BLVD
Mailing Address - Street 2:SUITE # 125
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-3353
Mailing Address - Country:US
Mailing Address - Phone:305-490-9641
Mailing Address - Fax:
Practice Address - Street 1:1000 PONCE DE LEON BLVD
Practice Address - Street 2:SUITE # 125
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-3353
Practice Address - Country:US
Practice Address - Phone:305-490-9641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4587103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075820500Medicaid