Provider Demographics
NPI:1700651478
Name:FORTINI, LEYDI JOHANA
Entity Type:Individual
Prefix:
First Name:LEYDI
Middle Name:JOHANA
Last Name:FORTINI
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 1:21326 GOSIER WAY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-4839
Mailing Address - Country:US
Mailing Address - Phone:305-509-9619
Mailing Address - Fax:
Practice Address - Street 1:7301A W PALMETTO PARK RD STE 100C
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3403
Practice Address - Country:US
Practice Address - Phone:954-248-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23310435106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician