Provider Demographics
NPI:1922884618
Name:CONSUEGRA, CRYSTIAN
Entity Type:Individual
Prefix:
First Name:CRYSTIAN
Middle Name:
Last Name:CONSUEGRA
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 1:2821 14TH ST W
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-5492
Mailing Address - Country:US
Mailing Address - Phone:239-671-4127
Mailing Address - Fax:
Practice Address - Street 1:2821 14TH ST W
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-5492
Practice Address - Country:US
Practice Address - Phone:239-671-4127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-393740106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty