Provider Demographics
NPI:1710588991
Name:NOGUERA, MARIO JESUS (RBT)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:JESUS
Last Name:NOGUERA
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18179 NW 73RD AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-6198
Mailing Address - Country:US
Mailing Address - Phone:786-661-0260
Mailing Address - Fax:
Practice Address - Street 1:18179 NW 73RD AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-6198
Practice Address - Country:US
Practice Address - Phone:786-661-0260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-136459106S00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-136459Medicaid