Provider Demographics
NPI:1538921069
Name:LEGUIZAMON, AILEN AGOSTINA
Entity type:Individual
Prefix:
First Name:AILEN
Middle Name:AGOSTINA
Last Name:LEGUIZAMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13195 SW 9TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2021
Mailing Address - Country:US
Mailing Address - Phone:786-218-9824
Mailing Address - Fax:
Practice Address - Street 1:111 NW 183RD ST STE 404
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-4619
Practice Address - Country:US
Practice Address - Phone:786-708-2286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW191911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical