Provider Demographics
NPI:1902417280
Name:TIELVES LAZO, FIDEL Y
Entity Type:Individual
Prefix:
First Name:FIDEL
Middle Name:Y
Last Name:TIELVES 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 1:13501 SW 118TH PASS
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-5251
Mailing Address - Country:US
Mailing Address - Phone:786-339-0069
Mailing Address - Fax:
Practice Address - Street 1:13501 SW 118TH PASS
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5251
Practice Address - Country:US
Practice Address - Phone:786-339-0069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLT412259770140106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician