Provider Demographics
NPI:1134877426
Name:TOUKOLON, ALICE
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:TOUKOLON
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 1:795 SW 110TH AVE # 1615
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1349
Mailing Address - Country:US
Mailing Address - Phone:301-765-4948
Mailing Address - Fax:
Practice Address - Street 1:14645 NW 77TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2569
Practice Address - Country:US
Practice Address - Phone:754-812-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2023-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-202530106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113406600Medicaid