Provider Demographics
NPI:1689218562
Name:BOYZO, ANGELINA
Entity type:Individual
Prefix:
First Name:ANGELINA
Middle Name:
Last Name:BOYZO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 E EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-3666
Mailing Address - Country:US
Mailing Address - Phone:813-655-8159
Mailing Address - Fax:
Practice Address - Street 1:2019 E EDGEWOOD DR STE 130
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3667
Practice Address - Country:US
Practice Address - Phone:813-655-8159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-96775106S00000X
FL106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104110600Medicaid