MEDICARE: LIZANDRA PALENZUELA

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	BACB762556	FL

General Provider Information

NPI Number	:	1992442339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIZANDRA PALENZUELA

Provider Business Mailing Address
First Line	:	2005 SW 145TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-7468
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3219 W 4TH AVE
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-5308
Country	:	US
Telephone Number	:	305-261-6633
Fax Number	:

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

Provider Enumeration Date	:	05/17/2022
Last Update Date	:	05/18/2022

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