Provider Demographics
NPI:1255149118
Name:MENDEZ MIURA, LOURDES M
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:M
Last Name:MENDEZ MIURA
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 1:4096 LAKE BOSSE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-1905
Mailing Address - Country:US
Mailing Address - Phone:407-970-4294
Mailing Address - Fax:
Practice Address - Street 1:1200 N CENTRAL AVE STE 110
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4439
Practice Address - Country:US
Practice Address - Phone:407-530-5063
Practice Address - Fax:877-399-5578
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-24
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No252Y00000XAgenciesEarly Intervention Provider Agency