Provider Demographics
NPI:1629710355
Name:LAZA ZULUETA, LETTYS Y
Entity Type:Individual
Prefix:
First Name:LETTYS
Middle Name:Y
Last Name:LAZA ZULUETA
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 1:6060 NW 186TH ST APT 204
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-8054
Mailing Address - Country:US
Mailing Address - Phone:786-556-8989
Mailing Address - Fax:
Practice Address - Street 1:6060 NW 186TH ST APT 204
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-8054
Practice Address - Country:US
Practice Address - Phone:786-556-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-203513106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113993100Medicaid