Provider Demographics
NPI:1366283236
Name:LAGOA ORTEGA, MADILEIDY SR
Entity type:Individual
Prefix:
First Name:MADILEIDY
Middle Name:
Last Name:LAGOA ORTEGA
Suffix:SR
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 1:1700 SW 127TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-1252
Mailing Address - Country:US
Mailing Address - Phone:305-337-8920
Mailing Address - Fax:
Practice Address - Street 1:1700 SW 127TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-1252
Practice Address - Country:US
Practice Address - Phone:305-337-8920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-351-1182106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician