Provider Demographics
NPI:1619680295
Name:LIZARDI, JOSE LUIS IV
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:LUIS
Last Name:LIZARDI
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 N ALBANY AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-1261
Mailing Address - Country:US
Mailing Address - Phone:315-244-0615
Mailing Address - Fax:
Practice Address - Street 1:454 W PIPKIN RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2545
Practice Address - Country:US
Practice Address - Phone:863-619-2809
Practice Address - Fax:813-646-9590
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician