Provider Demographics
NPI:1427756378
Name:LEY COSSIO, ALFONSO ISMAEL
Entity type:Individual
Prefix:
First Name:ALFONSO
Middle Name:ISMAEL
Last Name:LEY COSSIO
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 1:11591 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-4326
Mailing Address - Country:US
Mailing Address - Phone:786-326-7571
Mailing Address - Fax:
Practice Address - Street 1:11591 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-4326
Practice Address - Country:US
Practice Address - Phone:786-326-7571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-258665106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician