Provider Demographics
NPI:1194176438
Name:ALONSO, LETICIA
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:ALONSO
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 1:13155 SW 134TH ST STE 115
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4487
Mailing Address - Country:US
Mailing Address - Phone:786-429-3738
Mailing Address - Fax:305-397-2416
Practice Address - Street 1:13155 SW 134TH ST STE 115
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4487
Practice Address - Country:US
Practice Address - Phone:786-429-3738
Practice Address - Fax:305-397-2416
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL374U00000X, 106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1961538OtherWELLCARE
FL005564800Medicaid
FL003015700OtherMEDICAID WAIVER
FL017450000OtherBEHAVIOR ANALYSIST GROUP