Provider Demographics
NPI:1942600978
Name:CORUJO, ALEJANDRA
Entity Type:Individual
Prefix:
First Name:ALEJANDRA
Middle Name:
Last Name:CORUJO
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 1:17900 NW 5TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-2809
Mailing Address - Country:US
Mailing Address - Phone:954-388-0800
Mailing Address - Fax:
Practice Address - Street 1:17900 NW 5TH ST STE 103
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-2809
Practice Address - Country:US
Practice Address - Phone:954-388-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-42367103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1-20-42367OtherLICENSE