Healthcare Provider Details

I. General information

NPI: 1215522701
Provider Name (Legal Business Name): LILIAN LAZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 NE 12TH AVE LOT 39
HOMESTEAD FL
33030-6229
US

IV. Provider business mailing address

220 NE 12TH AVE LOT 39
HOMESTEAD FL
33030-6229
US

V. Phone/Fax

Practice location:
  • Phone: 786-624-1297
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: