Healthcare Provider Details

I. General information

NPI: 1811513393
Provider Name (Legal Business Name): DIEGO MANUEL LEON VEGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 12/31/2023
Certification Date: 12/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13590 SW 134TH AVE STE 202
MIAMI FL
33186-4576
US

IV. Provider business mailing address

15125 SW 180TH ST
MIAMI FL
33187-6314
US

V. Phone/Fax

Practice location:
  • Phone: 305-588-4988
  • Fax:
Mailing address:
  • Phone: 305-588-4988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH21582
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: