Provider Demographics
NPI:1558615195
Name:MENESES, ALFONSO
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
Last Name:MENESES
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 1:11060 N KENDALL DR
Mailing Address - Street 2:SUITE 501
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1272
Mailing Address - Country:US
Mailing Address - Phone:305-668-8644
Mailing Address - Fax:305-668-8644
Practice Address - Street 1:11060 N KENDALL DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1272
Practice Address - Country:US
Practice Address - Phone:305-668-8644
Practice Address - Fax:305-668-3010
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program