MEDICARE: LIDERAZGO Y ESTILO DE VIDA TRANSFORMACIONAL, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251300000X	Local Education Agency (LEA)
2	251B00000X	Case Management Agency
3	261QM0850X	Adult Mental Health Clinic/Center
4	261QM0855X	Adolescent and Children Mental Health Clinic/Center
5	261QS1000X	Student Health Clinic/Center
6	276400000X	Substance Use Disorder Rehabilitation Hospital Unit
7	282J00000X	Religious Nonmedical Health Care Institution
8	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1386295095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIDERAZGO Y ESTILO DE VIDA TRANSFORMACIONAL, INC

Provider Business Mailing Address
First Line	:	1604 17TH TER NE
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-4416
Country	:	US
Telephone Number	:	863-288-1635
Fax Number	:

Provider Business Practice Location Address
First Line	:	1604 17TH TER NE
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-4416
Country	:	US
Telephone Number	:	863-288-1635
Fax Number	:

Authorized Official
Title or Position	:	MENTAL HEALTH CARE
Name	:	MR. ABRAHAM TIRADO AYALA
Credential	:	CBHCM
Telephone Number	:	863-288-1635

Provider Enumeration Date	:	09/24/2019
Last Update Date	:	07/23/2021

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