Provider Demographics
NPI:1174352686
Name:BORREGO, EUDDY DAMIAN
Entity type:Individual
Prefix:
First Name:EUDDY
Middle Name:DAMIAN
Last Name:BORREGO
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 1:16136 SW 147TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-6410
Mailing Address - Country:US
Mailing Address - Phone:786-209-5382
Mailing Address - Fax:
Practice Address - Street 1:16136 SW 147TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-6410
Practice Address - Country:US
Practice Address - Phone:786-209-5382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-01
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-362957106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty