Provider Demographics
NPI:1356074991
Name:LIZCANO, GEORGE ANTHONY (RBT-20-13079)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:ANTHONY
Last Name:LIZCANO
Suffix:
Gender:M
Credentials:RBT-20-13079
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18119 NW 90 AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-6556
Mailing Address - Country:US
Mailing Address - Phone:786-479-5398
Mailing Address - Fax:
Practice Address - Street 1:6625 MIAMI LAKES DR SUITE 374
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2710
Practice Address - Country:US
Practice Address - Phone:305-777-3883
Practice Address - Fax:305-777-3837
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-130379106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107537800Medicaid