Provider Demographics
NPI:1689380313
Name:ALFONSO VALDES, GABRIEL I
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:I
Last Name:ALFONSO VALDES
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 1:2224 VILLA VERANO WAY
Mailing Address - Street 2:APTM # 103
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-6376
Mailing Address - Country:US
Mailing Address - Phone:561-502-8458
Mailing Address - Fax:
Practice Address - Street 1:2224 VILLA VERANO WAY
Practice Address - Street 2:APTM # 103
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-6376
Practice Address - Country:US
Practice Address - Phone:561-502-8458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-254141106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician