Provider Demographics
NPI:1568029502
Name:HERNANDEZ OLIVA, LAZARA
Entity Type:Individual
Prefix:
First Name:LAZARA
Middle Name:
Last Name:HERNANDEZ OLIVA
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 1:6930 NW 179TH ST APT 205
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5647
Mailing Address - Country:US
Mailing Address - Phone:786-366-2235
Mailing Address - Fax:
Practice Address - Street 1:6930 NW 179TH ST APT 205
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5647
Practice Address - Country:US
Practice Address - Phone:786-366-2235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-24
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician