Provider Demographics
NPI:1659131779
Name:GARCIA RODRIGUEZ, RAISA LESLIE
Entity Type:Individual
Prefix:
First Name:RAISA
Middle Name:LESLIE
Last Name:GARCIA RODRIGUEZ
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 1:1106 W PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-2939
Mailing Address - Country:US
Mailing Address - Phone:786-383-6850
Mailing Address - Fax:
Practice Address - Street 1:1106 W PLEASANT ST
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-2939
Practice Address - Country:US
Practice Address - Phone:786-383-6850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-318750106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician