Provider Demographics
NPI:1750097614
Name:IGLESIAS, PAOLA
Entity type:Individual
Prefix:
First Name:PAOLA
Middle Name:
Last Name:IGLESIAS
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 1:865 SPAULDING ST E
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33974-7123
Mailing Address - Country:US
Mailing Address - Phone:239-841-9731
Mailing Address - Fax:
Practice Address - Street 1:8359 BEACON BLVD STE 416
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3065
Practice Address - Country:US
Practice Address - Phone:239-676-3462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38056609Medicaid