Provider Demographics
NPI:1942548441
Name:DEPENA, YUDELKA (ITDS)
Entity Type:Individual
Prefix:
First Name:YUDELKA
Middle Name:
Last Name:DEPENA
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-4464
Mailing Address - Country:US
Mailing Address - Phone:917-474-7870
Mailing Address - Fax:
Practice Address - Street 1:2324 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-4464
Practice Address - Country:US
Practice Address - Phone:917-474-7870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-18
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011151500Medicaid