MEDICARE: YISSED ORTEGA IZQUIERDO

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	20134624	CO

General Provider Information

NPI Number	:	1780283440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YISSED ORTEGA IZQUIERDO

Provider Business Mailing Address
First Line	:	4510 W IDLEWILD AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-5438
Country	:	US
Telephone Number	:	813-453-5674
Fax Number	:

Provider Business Practice Location Address
First Line	:	4510 W IDLEWILD AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-5438
Country	:	US
Telephone Number	:	813-453-5674
Fax Number	:

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

Provider Enumeration Date	:	10/22/2020
Last Update Date	:	09/21/2021

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Directions to “ YISSED ORTEGA IZQUIERDO ” Practice Location

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