MEDICARE: VIVIANA LAZARA ESPINOSA HERNANDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-24-397118	FL

General Provider Information

NPI Number	:	1134935976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIVIANA LAZARA ESPINOSA HERNANDEZ

Provider Business Mailing Address
First Line	:	123 NW 7TH ST
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33993-1806
Country	:	US
Telephone Number	:	239-414-8423
Fax Number	:	239-414-8423

Provider Business Practice Location Address
First Line	:	123 NW 7TH ST
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33993-1806
Country	:	US
Telephone Number	:	239-414-8423
Fax Number	:	239-414-8423

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2024
Last Update Date	:	12/21/2024

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