Provider Demographics
NPI:1588351050
Name:IZQUIERDO SANCHEZ, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:IZQUIERDO SANCHEZ
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 1:11780 SW 18TH ST APT 531
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-8782
Mailing Address - Country:US
Mailing Address - Phone:786-720-5252
Mailing Address - Fax:
Practice Address - Street 1:12540 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-1412
Practice Address - Country:US
Practice Address - Phone:305-705-6840
Practice Address - Fax:786-655-0185
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW18551101YM0800X
FLCBHCMS0102652171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCBHCMS0102652OtherFLORIDA CERTIFICATION BOARD
FLISW18551OtherFLORIDA HEALTH DEPARTMENT
FLCBHCM0102433OtherFLORIDA CERTIFICATION BOARD