Provider Demographics
NPI:1114617958
Name:MARTINEZ AVILA, LAZARO (BACB891015)
Entity Type:Individual
Prefix:
First Name:LAZARO
Middle Name:
Last Name:MARTINEZ AVILA
Suffix:
Gender:M
Credentials:BACB891015
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 FIELDSTREAM WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-7235
Mailing Address - Country:US
Mailing Address - Phone:689-444-7007
Mailing Address - Fax:
Practice Address - Street 1:437 FIELDSTREAM WEST BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-7235
Practice Address - Country:US
Practice Address - Phone:689-444-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-269052106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician