Provider Demographics
NPI:1528618840
Name:SARDINAS, AGUEDA M
Entity type:Individual
Prefix:
First Name:AGUEDA
Middle Name:M
Last Name:SARDINAS
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 1:1271 W 79TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3445
Mailing Address - Country:US
Mailing Address - Phone:786-445-3046
Mailing Address - Fax:
Practice Address - Street 1:2401 SW 37TH AVE STE 211
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-3045
Practice Address - Country:US
Practice Address - Phone:305-783-4286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-82206106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1033677900Medicaid