MEDICARE: VIDAL LAZO RMHCI

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	101YM0800X	Mental Health Counselor	21331	FL

General Provider Information

NPI Number	:	1245973205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIDAL LAZO RMHCI

Provider Business Mailing Address
First Line	:	4649 PONCE DE LEON BLVD
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33146-2114
Country	:	US
Telephone Number	:	786-287-8828
Fax Number	:

Provider Business Practice Location Address
First Line	:	4649 PONCE DE LEON BLVD
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33146-2114
Country	:	US
Telephone Number	:	786-287-8828
Fax Number	:

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

Provider Enumeration Date	:	04/18/2022
Last Update Date	:	04/18/2022

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