Provider Demographics
NPI:1003589045
Name:LEON JORGE, MAGALIS TAINELY
Entity Type:Individual
Prefix:
First Name:MAGALIS
Middle Name:TAINELY
Last Name:LEON JORGE
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 1:4421 NW 191ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-2113
Mailing Address - Country:US
Mailing Address - Phone:786-712-0186
Mailing Address - Fax:
Practice Address - Street 1:4421 NW 191ST ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-2113
Practice Address - Country:US
Practice Address - Phone:786-712-0186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-137159106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty