MEDICARE: RAYSA M BERMEO LAZO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063114999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYSA M BERMEO LAZO

Provider Business Mailing Address
First Line	:	4300 SHERIDAN ST APT 201
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-3503
Country	:	US
Telephone Number	:	754-423-3366
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 SHERIDAN ST APT 201
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-3503
Country	:	US
Telephone Number	:	754-423-3366
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2023
Last Update Date	:	03/22/2023

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Directions to “ RAYSA M BERMEO LAZO ” Practice Location

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