Provider Demographics
NPI:1295327799
Name:JUSTIZ DUSSU, YOHAGNIS
Entity type:Individual
Prefix:
First Name:YOHAGNIS
Middle Name:
Last Name:JUSTIZ DUSSU
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 1:722 E 27TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-3640
Mailing Address - Country:US
Mailing Address - Phone:305-720-0701
Mailing Address - Fax:
Practice Address - Street 1:722 E 27TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3640
Practice Address - Country:US
Practice Address - Phone:305-720-0701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJ232-960-78-588-0106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108284600Medicaid