Provider Demographics
NPI:1235635061
Name:LEZCANO, GILBERTO
Entity Type:Individual
Prefix:
First Name:GILBERTO
Middle Name:
Last Name:LEZCANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 NW 12 AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168
Mailing Address - Country:US
Mailing Address - Phone:305-244-4794
Mailing Address - Fax:
Practice Address - Street 1:11000 NW 12 AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33168
Practice Address - Country:US
Practice Address - Phone:305-244-4794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023470800Medicaid