Provider Demographics
NPI:1396990487
Name:MACEDA, JORGE LUIS (MS, BCBA)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:MACEDA
Suffix:
Gender:M
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 NW 8TH ST APT 305
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3767
Mailing Address - Country:US
Mailing Address - Phone:786-357-7808
Mailing Address - Fax:305-675-4632
Practice Address - Street 1:8401 NW 8TH ST APT 305
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-3767
Practice Address - Country:US
Practice Address - Phone:786-357-7808
Practice Address - Fax:305-675-4632
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FL1-21-56278103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014134000Medicaid