Healthcare Provider Details

I. General information

NPI: 1275366924
Provider Name (Legal Business Name): KATHLEEN ANGELICA CUELLAR PRADO MS, EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 QUINCY AVE
FORT PIERCE FL
34947-4766
US

IV. Provider business mailing address

1500 CENTREPARK BLVD APT 317
WEST PALM BEACH FL
33401-7455
US

V. Phone/Fax

Practice location:
  • Phone: 786-261-5497
  • Fax:
Mailing address:
  • Phone: 786-261-5497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS1857
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: