Provider Demographics
NPI:1730695933
Name:CHACON ASUSTA, LEONARDO LORENZO
Entity type:Individual
Prefix:
First Name:LEONARDO
Middle Name:LORENZO
Last Name:CHACON ASUSTA
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 1:4490 SW 5TH TER
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-1961
Mailing Address - Country:US
Mailing Address - Phone:305-298-4089
Mailing Address - Fax:
Practice Address - Street 1:4490 SW 5 TERR
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134
Practice Address - Country:US
Practice Address - Phone:305-298-4089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-26
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW150071041C0700X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023396400Medicaid