Provider Demographics
NPI:1255043899
Name:HERRERA ALFONSO, JUAN CARLOS
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:HERRERA ALFONSO
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 1:10618 EGRET HAVEN LN
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-3360
Mailing Address - Country:US
Mailing Address - Phone:305-305-8162
Mailing Address - Fax:
Practice Address - Street 1:10618 EGRET HAVEN LN
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3360
Practice Address - Country:US
Practice Address - Phone:305-305-8162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-248796106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty