Provider Demographics
NPI:1487470563
Name:LEON VAZQUEZ, RAUL ALEJANDRO
Entity type:Individual
Prefix:
First Name:RAUL
Middle Name:ALEJANDRO
Last Name:LEON VAZQUEZ
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 1:872 SW 7TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORIDA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33034-5601
Mailing Address - Country:US
Mailing Address - Phone:786-720-0259
Mailing Address - Fax:
Practice Address - Street 1:872 SW 7TH ST
Practice Address - Street 2:
Practice Address - City:FLORIDA CITY
Practice Address - State:FL
Practice Address - Zip Code:33034-5601
Practice Address - Country:US
Practice Address - Phone:786-720-0259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-23
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-385124106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician