MEDICARE: LISANDRA GAMBOA HERNANDEZ RBT

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	:	1194474114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISANDRA GAMBOA HERNANDEZ RBT

Provider Business Mailing Address
First Line	:	4360 SW 108TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33165-4850
Country	:	US
Telephone Number	:	786-484-4116
Fax Number	:

Provider Business Practice Location Address
First Line	:	4360 SW 108TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33165-4850
Country	:	US
Telephone Number	:	786-484-4116
Fax Number	:

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

Provider Enumeration Date	:	03/18/2022
Last Update Date	:	03/18/2022

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