Healthcare Provider Details

I. General information

NPI: 1104753839
Provider Name (Legal Business Name): ITAYNA GORDO LAUZURIQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 SE 46TH LN STE 2
CAPE CORAL FL
33904-8647
US

IV. Provider business mailing address

2008 NW 7TH ST
CAPE CORAL FL
33993-7128
US

V. Phone/Fax

Practice location:
  • Phone: 239-257-1572
  • Fax:
Mailing address:
  • Phone: 239-321-4696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-496572
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: