Provider Demographics
NPI:1578235552
Name:ALFONSO, DISLAISIS
Entity Type:Individual
Prefix:
First Name:DISLAISIS
Middle Name:
Last Name:ALFONSO
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 1:5400 SW 77TH CT APT 1H
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-4344
Mailing Address - Country:US
Mailing Address - Phone:305-889-9047
Mailing Address - Fax:
Practice Address - Street 1:5400 SW 77TH CT APT 1H
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4344
Practice Address - Country:US
Practice Address - Phone:305-889-9047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20146597106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician