MEDICARE: LIETY MEDEROS

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

General Provider Information

NPI Number	:	1154283976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIETY MEDEROS

Provider Business Mailing Address
First Line	:	3500 DEPAUW BLVD STE 3070
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-6135
Country	:	US
Telephone Number	:	855-324-0885
Fax Number	:	317-520-8200

Provider Business Practice Location Address
First Line	:	3491 GANDY PARK
Second Line	:	SUITE 100
City	:	PINELLAS PARK
State	:	FL
Zip	:	33781
Country	:	US
Telephone Number	:	727-390-2211
Fax Number	:

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

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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Directions to “ LIETY MEDEROS ” Practice Location

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