Provider Demographics
NPI:1760241863
Name:SOSA MACIAS, NELSON R
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:R
Last Name:SOSA MACIAS
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 1:1485 W 46TH ST APT 310A
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7177
Mailing Address - Country:US
Mailing Address - Phone:786-532-6394
Mailing Address - Fax:
Practice Address - Street 1:1485 W 46TH ST APT 310A
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7177
Practice Address - Country:US
Practice Address - Phone:786-532-6394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-323852106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty