Provider Demographics
NPI:1780414052
Name:CASA BANGO, ADRIAN JESUS
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:JESUS
Last Name:CASA BANGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5637 BASIL DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-7013
Mailing Address - Country:US
Mailing Address - Phone:786-312-9828
Mailing Address - Fax:
Practice Address - Street 1:5637 BASIL DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33415-7013
Practice Address - Country:US
Practice Address - Phone:786-312-9828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC215-010-01-171-0106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician