Provider Demographics
NPI:1356938419
Name:RODRIGUEZ LEYVA, CARLOS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:RODRIGUEZ LEYVA
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 1:4117 NE 24TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-5101
Mailing Address - Country:US
Mailing Address - Phone:305-970-2455
Mailing Address - Fax:
Practice Address - Street 1:4117 NE 24TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-5101
Practice Address - Country:US
Practice Address - Phone:305-970-2455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-12760106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty