Provider Demographics
NPI:1962088120
Name:DE LEON, EDGARDO ARIEL
Entity type:Individual
Prefix:
First Name:EDGARDO
Middle Name:ARIEL
Last Name:DE LEON
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 1:501 E DANIA BEACH BLVD APT 1L
Mailing Address - Street 2:
Mailing Address - City:DANIA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33004-3010
Mailing Address - Country:US
Mailing Address - Phone:954-651-0706
Mailing Address - Fax:
Practice Address - Street 1:8785 SW 165TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-5827
Practice Address - Country:US
Practice Address - Phone:786-206-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician