Provider Demographics
NPI:1346807690
Name:LAUZURIQUE TENORIO, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:LAUZURIQUE TENORIO
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 1:1750 W 56TH ST APT 122
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2065
Mailing Address - Country:US
Mailing Address - Phone:786-328-2770
Mailing Address - Fax:
Practice Address - Street 1:1750 W 56TH ST APT 122
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2065
Practice Address - Country:US
Practice Address - Phone:786-328-2770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-21-50492103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty