Provider Demographics
NPI:1144917725
Name:CESPEDES SOCARRAS, GUSTAVO MANUEL (RBT)
Entity type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:MANUEL
Last Name:CESPEDES SOCARRAS
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 GOLDENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6402
Mailing Address - Country:US
Mailing Address - Phone:813-525-2574
Mailing Address - Fax:
Practice Address - Street 1:102 GOLDENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6402
Practice Address - Country:US
Practice Address - Phone:813-525-2574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-23-269408106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty