Provider Demographics
NPI:1316757842
Name:PESTANA, GENOR
Entity type:Individual
Prefix:
First Name:GENOR
Middle Name:
Last Name:PESTANA
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 1:3031 NW 166TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33054-6447
Mailing Address - Country:US
Mailing Address - Phone:713-517-0309
Mailing Address - Fax:
Practice Address - Street 1:11300 NW 87TH CT STE 149
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-4520
Practice Address - Country:US
Practice Address - Phone:786-518-3452
Practice Address - Fax:786-518-3453
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT24382897106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician