Provider Demographics
NPI:1568115020
Name:OSORIO, LAURA LEE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:OSORIO
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 1:648 NW 122ND PSGE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2021
Mailing Address - Country:US
Mailing Address - Phone:305-297-9887
Mailing Address - Fax:
Practice Address - Street 1:780 NW 127TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33182-1895
Practice Address - Country:US
Practice Address - Phone:305-297-9887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL016266900251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016266900Medicaid