Provider Demographics
NPI:1154063543
Name:LEIVA, ALEXY
Entity Type:Individual
Prefix:
First Name:ALEXY
Middle Name:
Last Name:LEIVA
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 1:12179 COUNTRY GREENS BLVD
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-2039
Mailing Address - Country:US
Mailing Address - Phone:786-288-6409
Mailing Address - Fax:
Practice Address - Street 1:12179 COUNTRY GREENS BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-2039
Practice Address - Country:US
Practice Address - Phone:786-288-6409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-201830106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician