Provider Demographics
NPI:1659765808
Name:LEON JIMENEZ, GISELLE
Entity type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:LEON JIMENEZ
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 1:4241 SW 99TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-5140
Mailing Address - Country:US
Mailing Address - Phone:786-797-3958
Mailing Address - Fax:
Practice Address - Street 1:4241 SW 99TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-5140
Practice Address - Country:US
Practice Address - Phone:786-797-3958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2025-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT-2824103K00000X
FLMT2824106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017573600Medicaid