Provider Demographics
NPI:1134654650
Name:RODRIGUEZ LEIVA, EVAGNE
Entity Type:Individual
Prefix:
First Name:EVAGNE
Middle Name:
Last Name:RODRIGUEZ LEIVA
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 1:14710 SW 38TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-3946
Mailing Address - Country:US
Mailing Address - Phone:786-683-0921
Mailing Address - Fax:
Practice Address - Street 1:14710 SW 38TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185
Practice Address - Country:US
Practice Address - Phone:786-683-0921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103489900Medicaid