Provider Demographics
NPI:1568044121
Name:SALAZAR COSTALES, ILDELISA
Entity Type:Individual
Prefix:
First Name:ILDELISA
Middle Name:
Last Name:SALAZAR COSTALES
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 1:100 NW 87TH AVE APT E104
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4519
Mailing Address - Country:US
Mailing Address - Phone:786-458-0848
Mailing Address - Fax:
Practice Address - Street 1:100 NW 87TH AVE APT E104
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-4519
Practice Address - Country:US
Practice Address - Phone:786-458-0848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-20-11015106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty