Provider Demographics
NPI:1407625981
Name:ALFONSO PORTALES, LESTER JESUS
Entity Type:Individual
Prefix:
First Name:LESTER
Middle Name:JESUS
Last Name:ALFONSO PORTALES
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 1:12401 W OKEECHOBEE RD LOT 470
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-5906
Mailing Address - Country:US
Mailing Address - Phone:786-792-0854
Mailing Address - Fax:
Practice Address - Street 1:12401 W OKEECHOBEE RD LOT 470
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-5906
Practice Address - Country:US
Practice Address - Phone:786-792-0854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-27
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23315898106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician