Provider Demographics
NPI:1558141762
Name:GIMENO, LIA
Entity Type:Individual
Prefix:
First Name:LIA
Middle Name:
Last Name:GIMENO
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 1:30 E 39TH ST APT 314
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-2279
Mailing Address - Country:US
Mailing Address - Phone:786-909-8558
Mailing Address - Fax:
Practice Address - Street 1:30 E 39TH ST APT 314
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-2279
Practice Address - Country:US
Practice Address - Phone:786-909-8558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-300368106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician