Provider Demographics
NPI:1275968513
Name:LAZO SANTALLA, DENIA (BS / CBHCM-S)
Entity Type:Individual
Prefix:
First Name:DENIA
Middle Name:
Last Name:LAZO SANTALLA
Suffix:
Gender:F
Credentials:BS / CBHCM-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15295 SW 107TH LN APT 1016
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-4559
Mailing Address - Country:US
Mailing Address - Phone:786-227-0804
Mailing Address - Fax:
Practice Address - Street 1:3271 NW 7TH ST STE 203
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-4141
Practice Address - Country:US
Practice Address - Phone:786-220-6902
Practice Address - Fax:866-726-0526
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1275968513Medicaid