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General NPI Number Information
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NPI Number | 1184315236
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Entity Type | Individual
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Provider Name | IVIS LAZARA FUENTES DIAZ
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Gender | Female
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Dates
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Enumeration Date | 05/18/2023
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Last Update Date | 12/15/2025
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Provider Practice Location Address
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Address Line | 11625 SW 168TH TER
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City | MIAMI
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State | FL
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Zip | 33157-3955
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Country | US
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Telephone | 786-771-1206
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Fax |
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Provider Business Mailing Address
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Address Line | 11625 SW 168TH TER
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City | MIAMI
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State | FL
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Zip | 33157-3955
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Country | US
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Telephone | 786-771-1206
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | F532-412-91-847-0
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | BCBA-1-25-86289
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License Number State | FL
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