Provider Demographics
NPI:1609478056
Name:LEIVA, EDUARDO ESTEBAN
Entity type:Individual
Prefix:MR
First Name:EDUARDO
Middle Name:ESTEBAN
Last Name:LEIVA
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 1:8407 SW 22ND ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-5119
Mailing Address - Country:US
Mailing Address - Phone:305-915-3044
Mailing Address - Fax:
Practice Address - Street 1:782 NW 42ND AVE STE 329
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-5550
Practice Address - Country:US
Practice Address - Phone:305-915-3044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18490101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty