Provider Demographics
NPI:1710610795
Name:LAZO RODRIGUEZ, IDALMI
Entity Type:Individual
Prefix:
First Name:IDALMI
Middle Name:
Last Name:LAZO RODRIGUEZ
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 1:15522 SW 60TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2804
Mailing Address - Country:US
Mailing Address - Phone:305-439-7015
Mailing Address - Fax:
Practice Address - Street 1:15522 SW 60TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-2804
Practice Address - Country:US
Practice Address - Phone:305-439-7015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-127694106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-127694OtherBACB