Healthcare Provider Details

I. General information

NPI: 1801307699
Provider Name (Legal Business Name): ANGEL LUIS PENATE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 SW 3RD ST
CORAL GABLES FL
33134-1021
US

IV. Provider business mailing address

5525 SW 3RD ST
CORAL GABLES FL
33134-1021
US

V. Phone/Fax

Practice location:
  • Phone: 786-312-5335
  • Fax:
Mailing address:
  • Phone: 786-312-5335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-44598
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: