Healthcare Provider Details

I. General information

NPI: 1174312540
Provider Name (Legal Business Name): IVELICE D LOZANO OLIVER OWNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 SW 122ND AVE
MIAMI FL
33184-2406
US

IV. Provider business mailing address

959 SW 122ND AVE
MIAMI FL
33184-2406
US

V. Phone/Fax

Practice location:
  • Phone: 786-755-2953
  • Fax: 786-817-2341
Mailing address:
  • Phone: 786-755-2953
  • Fax: 786-817-2341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: