Provider Demographics
NPI:1457186678
Name:CHANG LEYVA, JOSE ERNESTO
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:ERNESTO
Last Name:CHANG 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 1:5220 NW 196TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-6157
Mailing Address - Country:US
Mailing Address - Phone:561-913-2782
Mailing Address - Fax:954-272-7110
Practice Address - Street 1:701 PROMENADE DR STE 250
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-6035
Practice Address - Country:US
Practice Address - Phone:954-399-2637
Practice Address - Fax:954-272-7110
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-370937106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician