Provider Demographics
NPI:1104654409
Name:NICOLAS DEL PINO, JORGE ALBERTO
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ALBERTO
Last Name:NICOLAS DEL PINO
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 1:3551 SW 9TH TER APT 417
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-4361
Mailing Address - Country:US
Mailing Address - Phone:954-669-0643
Mailing Address - Fax:
Practice Address - Street 1:2898 NW 79TH AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33122-1033
Practice Address - Country:US
Practice Address - Phone:786-646-9250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-348755106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician