Provider Demographics
NPI:1275039927
Name:FERNANDEZ, LAZARO YOANDRIS
Entity Type:Individual
Prefix:
First Name:LAZARO
Middle Name:YOANDRIS
Last Name:FERNANDEZ
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 1:21830 INGRAHAM AVENUE RD
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33190-1009
Mailing Address - Country:US
Mailing Address - Phone:786-548-8638
Mailing Address - Fax:
Practice Address - Street 1:10300 SW 72ND ST STE 114
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3038
Practice Address - Country:US
Practice Address - Phone:305-508-5580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-52343106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty