Provider Demographics
NPI:1053128751
Name:ALFONSO, PEDRO
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:
Last Name:ALFONSO
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 1:2881 SANDHILL RIDGE CT APT 114
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-7449
Mailing Address - Country:US
Mailing Address - Phone:786-454-5935
Mailing Address - Fax:
Practice Address - Street 1:2881 SANDHILL RIDGE CT APT 114
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7449
Practice Address - Country:US
Practice Address - Phone:786-454-5935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-391560106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician