Healthcare Provider Details

I. General information

NPI: 1376307538
Provider Name (Legal Business Name): LYNN COSTO VAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 SW 5TH TER
CORAL GABLES FL
33134-1919
US

IV. Provider business mailing address

4501 SW 5TH TER
CORAL GABLES FL
33134-1919
US

V. Phone/Fax

Practice location:
  • Phone: 954-410-1873
  • Fax:
Mailing address:
  • Phone: 954-410-1873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: