Provider Demographics
NPI:1124542279
Name:SALCEDO, PABLO JESUS
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:JESUS
Last Name:SALCEDO
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 1:1662 SE 27TH DR UNIT 107
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33035-2508
Mailing Address - Country:US
Mailing Address - Phone:786-910-6117
Mailing Address - Fax:
Practice Address - Street 1:144 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4328
Practice Address - Country:US
Practice Address - Phone:786-910-6117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician