Provider Demographics
NPI:1912762873
Name:PUENTES LUPERON, ANDY DANIEL
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:DANIEL
Last Name:PUENTES LUPERON
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 1:4535 GROVE ST APT 3
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33415-1363
Mailing Address - Country:US
Mailing Address - Phone:561-373-2005
Mailing Address - Fax:
Practice Address - Street 1:4535 GROVE ST APT 3
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:FL
Practice Address - Zip Code:33415-1363
Practice Address - Country:US
Practice Address - Phone:561-373-2005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician