Provider Demographics
NPI:1679087381
Name:COUSO CARNERO, ERNESTO
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:COUSO CARNERO
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 1:935 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-3730
Mailing Address - Country:US
Mailing Address - Phone:786-775-9270
Mailing Address - Fax:
Practice Address - Street 1:717 PONCE DE LEON BLVD STE 307
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-2070
Practice Address - Country:US
Practice Address - Phone:305-463-6690
Practice Address - Fax:305-463-6690
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician