Provider Demographics
NPI:1295480010
Name:SUAREZ VISTORTE, JOSE IGNACIO
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:IGNACIO
Last Name:SUAREZ VISTORTE
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 1:15751 SW 144TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-7210
Mailing Address - Country:US
Mailing Address - Phone:305-964-7594
Mailing Address - Fax:
Practice Address - Street 1:15751 SW 144TH PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-7210
Practice Address - Country:US
Practice Address - Phone:305-964-7594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12157240103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst