Provider Demographics
NPI:1851913727
Name:VAZQUEZ, LEIDY LISSETTE
Entity Type:Individual
Prefix:
First Name:LEIDY
Middle Name:LISSETTE
Last Name:VAZQUEZ
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 1:710 SW 114TH AVE APT C5
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1094
Mailing Address - Country:US
Mailing Address - Phone:786-269-5968
Mailing Address - Fax:
Practice Address - Street 1:710 SW 114TH AVE APT C5
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1094
Practice Address - Country:US
Practice Address - Phone:786-269-5968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-117191106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician