Provider Demographics
NPI:1164028700
Name:FRAGOSO TREJO, LILIETT
Entity Type:Individual
Prefix:
First Name:LILIETT
Middle Name:
Last Name:FRAGOSO TREJO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 SW 33RD TER
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-4336
Mailing Address - Country:US
Mailing Address - Phone:954-638-1195
Mailing Address - Fax:
Practice Address - Street 1:2230 SW 33RD TER
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-4336
Practice Address - Country:US
Practice Address - Phone:954-638-1195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT20135303106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician