Provider Demographics
NPI:1356129654
Name:CARBALLO LUGO, JEHYSEL
Entity type:Individual
Prefix:
First Name:JEHYSEL
Middle Name:
Last Name:CARBALLO LUGO
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 1:16214 COPPERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-1112
Mailing Address - Country:US
Mailing Address - Phone:786-399-9076
Mailing Address - Fax:
Practice Address - Street 1:16214 COPPERFIELD DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1112
Practice Address - Country:US
Practice Address - Phone:786-399-9076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-297758106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician