Provider Demographics
NPI:1922750884
Name:ACEVEDO, EZEQUIEL ENRIQUE
Entity Type:Individual
Prefix:
First Name:EZEQUIEL
Middle Name:ENRIQUE
Last Name:ACEVEDO
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 1:715 SPACIOUS SKY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-6428
Mailing Address - Country:US
Mailing Address - Phone:847-691-0446
Mailing Address - Fax:
Practice Address - Street 1:7400 BLANCO RD STE 115
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-4361
Practice Address - Country:US
Practice Address - Phone:210-657-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-22-200379106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician