Provider Demographics
NPI:1205340189
Name:LEON, GABRIEL ALFREDO
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ALFREDO
Last Name:LEON
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 1:12018 SW 110TH STREET CIR E
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-3820
Mailing Address - Country:US
Mailing Address - Phone:305-519-3188
Mailing Address - Fax:
Practice Address - Street 1:12018 SW 110TH STREET CIR E
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-3820
Practice Address - Country:US
Practice Address - Phone:305-519-3188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693397Medicaid