Healthcare Provider Details

I. General information

NPI: 1811651441
Provider Name (Legal Business Name): LIDIANA LIZETT VELAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2021
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5712 SW 148TH CT
MIAMI FL
33193-2474
US

IV. Provider business mailing address

5712 SW 148TH CT
MIAMI FL
33193-2474
US

V. Phone/Fax

Practice location:
  • Phone: 786-209-4716
  • Fax:
Mailing address:
  • Phone: 786-209-4716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-90364
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: