MEDICARE: PAULO LAZARO LCSW LLC

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	261QM0850X	Adult Mental Health Clinic/Center	SW5258	FL
2	1041C0700X	Clinical Social Worker	SW5258	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z9778Z	OTHER	FL	MEDICARE

General Provider Information

NPI Number	:	1255619714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAULO LAZARO LCSW LLC

Provider Business Mailing Address
First Line	:	13499 BISCAYNE BLVD
Second Line	:	SUITE 208
City	:	NORTH MIAMI
State	:	FL
Zip	:	33181-2043
Country	:	US
Telephone Number	:	305-206-2899
Fax Number	:	954-510-2079

Provider Business Practice Location Address
First Line	:	13499 BISCAYNE BLVD
Second Line	:	SUITE 208
City	:	NORTH MIAMI
State	:	FL
Zip	:	33181-2043
Country	:	US
Telephone Number	:	305-206-2899
Fax Number	:	954-510-2079

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. PAULO LAZARO
Credential	:	LCSW
Telephone Number	:	305-206-2899

Provider Enumeration Date	:	08/01/2011
Last Update Date	:	08/01/2011

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