Provider Demographics
NPI:1396249041
Name:BADLISSI, EDGAR
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:BADLISSI
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 1:5020 NW 79TH AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-4735
Mailing Address - Country:US
Mailing Address - Phone:305-559-5900
Mailing Address - Fax:
Practice Address - Street 1:5020 NW 79TH AVE APT 303
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-4735
Practice Address - Country:US
Practice Address - Phone:305-559-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician