Provider Demographics
NPI:1023631389
Name:CARRENO AVILES, ANGEL ENRIQUE
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:ENRIQUE
Last Name:CARRENO AVILES
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 1:26720 SW 142ND AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:NARANJA
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5404
Mailing Address - Country:US
Mailing Address - Phone:786-294-4349
Mailing Address - Fax:
Practice Address - Street 1:26720 SW 142ND AVE APT 104
Practice Address - Street 2:
Practice Address - City:NARANJA
Practice Address - State:FL
Practice Address - Zip Code:33032-5404
Practice Address - Country:US
Practice Address - Phone:786-294-4349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-117674106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician