MEDICARE: LISANDRA ORTEGA FONG

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	106E00000X	Assistant Behavior Analyst	BCABA-0-23-14855	FL
2	106S00000X	Behavior Technician	RBT-20-111309	FL
3	222Q00000X	Developmental Therapist
4	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1831722644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISANDRA ORTEGA FONG

Provider Business Mailing Address
First Line	:	1215 NW 189TH TER
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33169-3420
Country	:	US
Telephone Number	:	512-792-6672
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 NW 189TH TER
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33169-3420
Country	:	US
Telephone Number	:	512-792-6672
Fax Number	:

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

Provider Enumeration Date	:	02/20/2020
Last Update Date	:	07/09/2025

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Directions to “ LISANDRA ORTEGA FONG ” Practice Location

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