Provider Demographics
NPI:1689263683
Name:PUJALS MACIEKOWICH, ISAMAR DALISA
Entity Type:Individual
Prefix:
First Name:ISAMAR
Middle Name:DALISA
Last Name:PUJALS MACIEKOWICH
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 1:1239 NEWPORT CENTER DR
Mailing Address - Street 2:SUITE #101
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442
Mailing Address - Country:US
Mailing Address - Phone:754-444-3707
Mailing Address - Fax:
Practice Address - Street 1:1239 E NEWPORT CENTER DR STE 101
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-7711
Practice Address - Country:US
Practice Address - Phone:754-444-3707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-80347106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician