Provider Demographics
NPI:1770007353
Name:TREJO LEAL, DIPSY
Entity Type:Individual
Prefix:
First Name:DIPSY
Middle Name:
Last Name:TREJO LEAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14919 SW 80TH ST APT 112
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-3151
Mailing Address - Country:US
Mailing Address - Phone:516-849-7405
Mailing Address - Fax:
Practice Address - Street 1:14919 SW 80TH ST APT 112
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-3151
Practice Address - Country:US
Practice Address - Phone:516-849-7405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
BCABA0-19-10108106E00000X, 106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst