Provider Demographics
NPI:1225650336
Name:HIDALGO PAVON, LIENA
Entity Type:Individual
Prefix:
First Name:LIENA
Middle Name:
Last Name:HIDALGO PAVON
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 1:130 NW 57TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4712
Mailing Address - Country:US
Mailing Address - Phone:850-851-4827
Mailing Address - Fax:
Practice Address - Street 1:130 NW 57TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-4712
Practice Address - Country:US
Practice Address - Phone:850-851-4827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-116986106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician