Provider Demographics
NPI:1720683345
Name:COLON RODRIGUEZ, LYLLYMAR
Entity Type:Individual
Prefix:
First Name:LYLLYMAR
Middle Name:
Last Name:COLON 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 1:15590 SW 106TH LN APT 1106
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-3503
Mailing Address - Country:US
Mailing Address - Phone:786-246-9193
Mailing Address - Fax:
Practice Address - Street 1:100 NE 15TH ST STE 101D
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4564
Practice Address - Country:US
Practice Address - Phone:833-779-8646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10960103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist