Provider Demographics
NPI:1235990151
Name:PROENZA VERDECIA, ALEXEI SANTIAGO
Entity Type:Individual
Prefix:
First Name:ALEXEI
Middle Name:SANTIAGO
Last Name:PROENZA VERDECIA
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 1:2101 LUDLAM RD APT 440
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1887
Mailing Address - Country:US
Mailing Address - Phone:786-773-7813
Mailing Address - Fax:
Practice Address - Street 1:2101 LUDLAM RD APT 440
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1887
Practice Address - Country:US
Practice Address - Phone:786-773-7813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-322042106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician