Healthcare Provider Details

I. General information

NPI: 1336840305
Provider Name (Legal Business Name): MARICELIS LAZO OLIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 MAJOR DR
LAKE WORTH BEACH FL
33461-5717
US

IV. Provider business mailing address

1810 MAJOR DR
LAKE WORTH BEACH FL
33461-5717
US

V. Phone/Fax

Practice location:
  • Phone: 561-679-3646
  • Fax:
Mailing address:
  • Phone: 561-679-3646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-261773
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: