Provider Demographics
NPI:1215489901
Name:OJEDA SANJURJO, GIANCARLO (BCABA)
Entity type:Individual
Prefix:
First Name:GIANCARLO
Middle Name:
Last Name:OJEDA SANJURJO
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E NASA BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1900
Mailing Address - Country:US
Mailing Address - Phone:321-372-6813
Mailing Address - Fax:321-765-6434
Practice Address - Street 1:2180 JULIAN AVE NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4020
Practice Address - Country:US
Practice Address - Phone:321-372-6813
Practice Address - Fax:321-765-6434
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-20-11159106E00000X
FLRBT-17-32968106S00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022064200Medicaid