Provider Demographics
NPI:1437931763
Name:LEON PICO, EDGAR JOEL
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:JOEL
Last Name:LEON PICO
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 1:17055 SW 93RD ST APT 6-104
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-1188
Mailing Address - Country:US
Mailing Address - Phone:786-320-1732
Mailing Address - Fax:
Practice Address - Street 1:17055 SW 93RD ST APT 6-104
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-1188
Practice Address - Country:US
Practice Address - Phone:786-320-1732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-1583-163491106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician