Provider Demographics
NPI:1740756766
Name:LEDESMA HUETE, BORIS
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:LEDESMA HUETE
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 1:15650 SW 141ST CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-1099
Mailing Address - Country:US
Mailing Address - Phone:786-612-0746
Mailing Address - Fax:
Practice Address - Street 1:9290 HAMMOCKS BLVD STE 401
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-1347
Practice Address - Country:US
Practice Address - Phone:786-558-5694
Practice Address - Fax:786-913-7034
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-62936106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician