Provider Demographics
NPI:1003692658
Name:BENITEZ LAZA, SHIRLEY (BACB916617)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:BENITEZ LAZA
Suffix:
Gender:F
Credentials:BACB916617
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27484 SW 133RD PATH
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8286
Mailing Address - Country:US
Mailing Address - Phone:786-339-3003
Mailing Address - Fax:
Practice Address - Street 1:8001 W 26TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-2912
Practice Address - Country:US
Practice Address - Phone:786-444-5578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB916617106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician