Provider Demographics
NPI:1639924061
Name:IZQUIERDO, OSVALDO E
Entity Type:Individual
Prefix:
First Name:OSVALDO
Middle Name:E
Last Name:IZQUIERDO
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 1:8185 NW 7TH ST APT 422442
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4084
Mailing Address - Country:US
Mailing Address - Phone:786-626-3867
Mailing Address - Fax:
Practice Address - Street 1:480 E OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-4542
Practice Address - Country:US
Practice Address - Phone:786-343-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-335725106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician