Provider Demographics
NPI:1336720291
Name:REAL DE LA PAZ, AMANDA MARIA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIA
Last Name:REAL DE LA PAZ
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 1:5246 CANNON WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-4005
Mailing Address - Country:US
Mailing Address - Phone:305-560-4205
Mailing Address - Fax:
Practice Address - Street 1:1521 FOREST HILL BLVD STE 3B
Practice Address - Street 2:
Practice Address - City:LAKE CLARKE SHORES
Practice Address - State:FL
Practice Address - Zip Code:33406-6031
Practice Address - Country:US
Practice Address - Phone:561-506-3665
Practice Address - Fax:561-444-2458
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-136009106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician