Healthcare Provider Details

I. General information

NPI: 1730801945
Provider Name (Legal Business Name): PATXI NMN PEGUERO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/14/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 5TH AVE N
SAINT PETERSBURG FL
33713-7521
US

IV. Provider business mailing address

14419 CARIBBEAN BREEZE DR UNIT 102
TAMPA FL
33613-5366
US

V. Phone/Fax

Practice location:
  • Phone: 727-367-2273
  • Fax:
Mailing address:
  • Phone: 212-603-9827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH22987
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: