Provider Demographics
NPI:1598114050
Name:CASANOVA, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:CASANOVA
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 1:2806 SW 144TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-7443
Mailing Address - Country:US
Mailing Address - Phone:305-244-8462
Mailing Address - Fax:
Practice Address - Street 1:12345 SW 18TH ST APT 317
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-1518
Practice Address - Country:US
Practice Address - Phone:305-244-8462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-19-35992103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst