Provider Demographics
NPI:1427408434
Name:MORENO LAZO, MIRNA D
Entity Type:Individual
Prefix:
First Name:MIRNA
Middle Name:D
Last Name:MORENO LAZO
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 1:7740 CAMINO REAL APT G-301
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-7160
Mailing Address - Country:US
Mailing Address - Phone:786-491-1416
Mailing Address - Fax:
Practice Address - Street 1:7740 CAMINO REAL APT G-301
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-7160
Practice Address - Country:US
Practice Address - Phone:786-491-1416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician