Provider Demographics
NPI:1386417145
Name:IZQUIERDO CONCEPCION, YAIDELIN
Entity type:Individual
Prefix:
First Name:YAIDELIN
Middle Name:
Last Name:IZQUIERDO CONCEPCION
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 1:27173 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33983-2761
Mailing Address - Country:US
Mailing Address - Phone:239-699-4961
Mailing Address - Fax:
Practice Address - Street 1:1475 COLLINGSWOOD BLVD UNIT G
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1059
Practice Address - Country:US
Practice Address - Phone:941-999-4917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-304331106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician