Provider Demographics
NPI:1033940671
Name:ACOSTA, ANDY LUIS I
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:LUIS
Last Name:ACOSTA
Suffix:I
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 1:17511 NW 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-3619
Mailing Address - Country:US
Mailing Address - Phone:305-589-1778
Mailing Address - Fax:
Practice Address - Street 1:17511 NW 49TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-3619
Practice Address - Country:US
Practice Address - Phone:305-589-1778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician