Healthcare Provider Details

I. General information

NPI: 1710610795
Provider Name (Legal Business Name): IDALMI LAZO RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15522 SW 60TH ST
MIAMI FL
33193-2804
US

IV. Provider business mailing address

15522 SW 60TH ST
MIAMI FL
33193-2804
US

V. Phone/Fax

Practice location:
  • Phone: 305-439-7015
  • Fax:
Mailing address:
  • Phone: 305-439-7015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-127694
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: