Provider Demographics
NPI:1548973829
Name:TELLECHEA CASANOLA, ELIESER
Entity type:Individual
Prefix:
First Name:ELIESER
Middle Name:
Last Name:TELLECHEA CASANOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 SW PALM DR APT 208
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1943
Mailing Address - Country:US
Mailing Address - Phone:772-559-2322
Mailing Address - Fax:
Practice Address - Street 1:261 SW PALM DR APT 208
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1943
Practice Address - Country:US
Practice Address - Phone:772-559-2322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician