Provider Demographics
NPI:1790317287
Name:CANGAS LAZO, GERLEN (RBT)
Entity Type:Individual
Prefix:
First Name:GERLEN
Middle Name:
Last Name:CANGAS LAZO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8831 NW 111TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4568
Mailing Address - Country:US
Mailing Address - Phone:786-720-4480
Mailing Address - Fax:
Practice Address - Street 1:8831 NW 111TH TER
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-4568
Practice Address - Country:US
Practice Address - Phone:786-720-4480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-105497106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician