Provider Demographics
NPI:1003424185
Name:LEZCANO, MARILU (RBT)
Entity Type:Individual
Prefix:
First Name:MARILU
Middle Name:
Last Name:LEZCANO
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 W 29TH ST APT 6
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5724
Mailing Address - Country:US
Mailing Address - Phone:786-622-7155
Mailing Address - Fax:
Practice Address - Street 1:199 W 29TH ST APT 6
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5724
Practice Address - Country:US
Practice Address - Phone:786-622-7155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL374U00000X
FLRBT-20-122-174106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty