Provider Demographics
NPI:1730677352
Name:FLYNN LIENS, JESUS EMILIO
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:EMILIO
Last Name:FLYNN LIENS
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 1:355 NW 72ND AVE APT 404
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4387
Mailing Address - Country:US
Mailing Address - Phone:786-510-9119
Mailing Address - Fax:
Practice Address - Street 1:355 NW 72ND AVE APT 404
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-4387
Practice Address - Country:US
Practice Address - Phone:786-510-9119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-54414106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician