MEDICARE: LISMARY GONZALEZ POLO

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

General Provider Information

NPI Number	:	1891517785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISMARY GONZALEZ POLO

Provider Business Mailing Address
First Line	:	1400 CRICKET CLUB CIR APT 103
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-5931
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 CRICKET CLUB CIR APT 103
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-5931
Country	:	US
Telephone Number	:	407-409-5065
Fax Number	:

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

Provider Enumeration Date	:	10/30/2024
Last Update Date	:	10/30/2024

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