Provider Demographics
NPI:1164022018
Name:ELWIN, JALEESA
Entity Type:Individual
Prefix:
First Name:JALEESA
Middle Name:
Last Name:ELWIN
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 1:3519 CARUSO PL
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9035
Mailing Address - Country:US
Mailing Address - Phone:954-401-3556
Mailing Address - Fax:
Practice Address - Street 1:148 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5372
Practice Address - Country:US
Practice Address - Phone:321-972-4039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-21-12730106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst