Provider Demographics
NPI:1174176986
Name:MAGTANONG, PAULA
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:MAGTANONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 SANDY RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-2113
Mailing Address - Country:US
Mailing Address - Phone:850-842-8124
Mailing Address - Fax:
Practice Address - Street 1:355 BEAL PKWY NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-3917
Practice Address - Country:US
Practice Address - Phone:850-240-7576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-21
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-82332106S00000X
FL1-23-64980103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician