Provider Demographics
NPI:1790369379
Name:WONG HIERREZUELO, AMED LEONARDO
Entity type:Individual
Prefix:
First Name:AMED
Middle Name:LEONARDO
Last Name:WONG HIERREZUELO
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 1:131 SE 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-5949
Mailing Address - Country:US
Mailing Address - Phone:786-626-4552
Mailing Address - Fax:
Practice Address - Street 1:8743 SW 9TH TER STE 2
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-3235
Practice Address - Country:US
Practice Address - Phone:305-244-9157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-49707103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103276100Medicaid