Provider Demographics
NPI:1093102196
Name:SANJURJO SANCHEZ, ELIAGNE
Entity Type:Individual
Prefix:
First Name:ELIAGNE
Middle Name:
Last Name:SANJURJO SANCHEZ
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 1:7556 STIRLING RD APT 222
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-1509
Mailing Address - Country:US
Mailing Address - Phone:954-668-5080
Mailing Address - Fax:
Practice Address - Street 1:10650 W STATE ROAD 84 STE 206
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-4235
Practice Address - Country:US
Practice Address - Phone:954-634-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106E00000X
106S00000X, 3747P1801X, 106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014641900Medicaid