Provider Demographics
NPI:1063139434
Name:RISCO DUENAS, NOEL MIGUEL
Entity type:Individual
Prefix:
First Name:NOEL
Middle Name:MIGUEL
Last Name:RISCO DUENAS
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 1:15008 SW 71ST LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1911
Mailing Address - Country:US
Mailing Address - Phone:786-585-5613
Mailing Address - Fax:
Practice Address - Street 1:7875 NW 12TH ST STE 108
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1815
Practice Address - Country:US
Practice Address - Phone:786-269-3502
Practice Address - Fax:305-468-6154
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-216499106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician