Provider Demographics
NPI:1285359315
Name:MANGUAL RIVERA, LEYSHKA
Entity type:Individual
Prefix:
First Name:LEYSHKA
Middle Name:
Last Name:MANGUAL RIVERA
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 1:3103 CATHERINE WHEEL CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-5777
Mailing Address - Country:US
Mailing Address - Phone:407-269-0590
Mailing Address - Fax:
Practice Address - Street 1:5575 S SEMORAN BLVD STE 7
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-1781
Practice Address - Country:US
Practice Address - Phone:321-352-2492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-235701106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-22-235701Medicaid