Provider Demographics
NPI:1659808764
Name:LASTRA, SERGIO
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:LASTRA
Suffix:
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 1:1950 SW 122ND AVE APT 512
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-7352
Mailing Address - Country:US
Mailing Address - Phone:786-925-7530
Mailing Address - Fax:
Practice Address - Street 1:13595 SW 134TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4579
Practice Address - Country:US
Practice Address - Phone:305-780-2358
Practice Address - Fax:305-713-1207
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician