Provider Demographics
NPI:1942194006
Name:PROHENZA MACIAS, LIANELIS RAFAELA
Entity type:Individual
Prefix:
First Name:LIANELIS
Middle Name:RAFAELA
Last Name:PROHENZA MACIAS
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 1:333 LAURINA ST APT 111
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-0602
Mailing Address - Country:US
Mailing Address - Phone:980-403-5321
Mailing Address - Fax:
Practice Address - Street 1:333 LAURINA ST APT 111
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0602
Practice Address - Country:US
Practice Address - Phone:980-403-5321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-04
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-431889106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty