Provider Demographics
NPI:1760233340
Name:VAZQUEZ HIDALGO, LUIS ALEJANDRO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ALEJANDRO
Last Name:VAZQUEZ HIDALGO
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 1:206 UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-2713
Mailing Address - Country:US
Mailing Address - Phone:786-754-0172
Mailing Address - Fax:
Practice Address - Street 1:206 UTAH AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-2713
Practice Address - Country:US
Practice Address - Phone:786-754-0172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1017576106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician