Healthcare Provider Details

I. General information

NPI: 1184315236
Provider Name (Legal Business Name): IVIS LAZARA FUENTES DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11625 SW 168TH TER
MIAMI FL
33157-3955
US

IV. Provider business mailing address

11625 SW 168TH TER
MIAMI FL
33157-3955
US

V. Phone/Fax

Practice location:
  • Phone: 786-771-1206
  • Fax:
Mailing address:
  • Phone: 786-771-1206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberF532-412-91-847-0
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBCBA-1-25-86289
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: