Provider Demographics
NPI:1891240917
Name:TORRES, MA JOANNA BERGONIA
Entity Type:Individual
Prefix:
First Name:MA JOANNA
Middle Name:BERGONIA
Last Name:TORRES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MA JOANNA
Other - Middle Name:TORRES
Other - Last Name:PALMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1616 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-5787
Mailing Address - Country:US
Mailing Address - Phone:863-243-8268
Mailing Address - Fax:
Practice Address - Street 1:1616 OAK AVE
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-5787
Practice Address - Country:US
Practice Address - Phone:863-243-8268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059-834-837OtherUSCIS