Healthcare Provider Details

I. General information

NPI: 1457469280
Provider Name (Legal Business Name): KAIZA C CANALES MRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 12/20/2023
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17410 SR 50 STE 130
CLERMONT FL
34711-8188
US

IV. Provider business mailing address

5560 KEATON SPRINGS DR
LAKELAND FL
33811-1882
US

V. Phone/Fax

Practice location:
  • Phone: 407-717-1305
  • Fax:
Mailing address:
  • Phone: 787-406-7509
  • Fax: 787-406-7509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2049
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH21375
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: