Provider Demographics
NPI:1750143855
Name:DE LA HUERTA CABRERA, LUIS CARLOS
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:CARLOS
Last Name:DE LA HUERTA CABRERA
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 1:14354 SW 98TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-8818
Mailing Address - Country:US
Mailing Address - Phone:786-810-6541
Mailing Address - Fax:
Practice Address - Street 1:14354 SW 98TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-8818
Practice Address - Country:US
Practice Address - Phone:786-810-6541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-312536106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121228700Medicaid