=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457186678
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE ERNESTO CHANG LEYVA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2024
-----------------------------------------------------
Last Update Date | 09/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 PROMENADE DR STE 250
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-6035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-399-2637
-----------------------------------------------------
Fax | 954-272-7110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5220 NW 196TH TER
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33055-6157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-913-2782
-----------------------------------------------------
Fax | 954-272-7110
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-24-370937
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------