Provider Demographics
NPI:1134624596
Name:WALLIN, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:WALLIN
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 1:9705 FONTAINEBLEAU BLVD APT 111
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13205 SW 137TH AVE STE 222
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5336
Practice Address - Country:US
Practice Address - Phone:786-762-9776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02790900Medicaid