Provider Demographics
NPI:1871255117
Name:LAZO, MARCELO
Entity Type:Individual
Prefix:
First Name:MARCELO
Middle Name:
Last Name:LAZO
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 1:4301 W FLAGLER ST PH 1
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-1501
Mailing Address - Country:US
Mailing Address - Phone:269-547-3180
Mailing Address - Fax:
Practice Address - Street 1:4301 W FLAGLER ST PH 1
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1501
Practice Address - Country:US
Practice Address - Phone:269-547-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician