MEDICARE: GABRIELA LAZARA CORDOVA CANCIO RBT

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	295725	FL

General Provider Information

NPI Number	:	1245004449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELA LAZARA CORDOVA CANCIO RBT

Provider Business Mailing Address
First Line	:	7191 W 24TH AVE APT 63
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33016-6529
Country	:	US
Telephone Number	:	786-961-7443
Fax Number	:

Provider Business Practice Location Address
First Line	:	7191 W 24TH AVE APT 63
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33016-6529
Country	:	US
Telephone Number	:	786-961-7443
Fax Number	:

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

Provider Enumeration Date	:	11/08/2023
Last Update Date	:	11/08/2023

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