Provider Demographics
NPI:1023824992
Name:TEBAS SACASA, AHMED ALFONSO
Entity type:Individual
Prefix:
First Name:AHMED
Middle Name:ALFONSO
Last Name:TEBAS SACASA
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 1:7379 NW 173RD DR
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-8484
Mailing Address - Country:US
Mailing Address - Phone:786-909-1849
Mailing Address - Fax:
Practice Address - Street 1:3350 SW 148TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-3237
Practice Address - Country:US
Practice Address - Phone:786-346-9021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-275161106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician