Provider Demographics
NPI:1972351492
Name:DE LA PENA VAZQUEZ, CARLOS DANIEL
Entity type:Individual
Prefix:
First Name:CARLOS DANIEL
Middle Name:
Last Name:DE LA PENA 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 1:68 ESSEX AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-5040
Mailing Address - Country:US
Mailing Address - Phone:786-260-3240
Mailing Address - Fax:
Practice Address - Street 1:68 ESSEX AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-5040
Practice Address - Country:US
Practice Address - Phone:786-260-3240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-133252106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician