Provider Demographics
NPI:1538453139
Name:LUIS, JEANNE (BCBA)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:LUIS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12973 SW 112 ST #151
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4768
Mailing Address - Country:US
Mailing Address - Phone:305-204-7037
Mailing Address - Fax:786-228-2555
Practice Address - Street 1:12973 SW 112 ST #151
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5826
Practice Address - Country:US
Practice Address - Phone:786-558-6133
Practice Address - Fax:786-228-2555
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-01
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-17-29089103K00000X
FL0-12-4458103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018395600Medicaid