=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720683345
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYLLYMAR COLON RODRIGUEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2020
-----------------------------------------------------
Last Update Date | 12/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 NE 15TH ST STE 101D
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33030-4564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-779-8646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15590 SW 106TH LN APT 1106
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33196-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-246-9193
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 10960
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------