Provider Demographics
NPI:1740928126
Name:SICRE RENDON, LAZARA
Entity type:Individual
Prefix:
First Name:LAZARA
Middle Name:
Last Name:SICRE RENDON
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 1:19800 SW 180TH AVE LOT 294
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33187-2640
Mailing Address - Country:US
Mailing Address - Phone:786-538-9583
Mailing Address - Fax:
Practice Address - Street 1:1905 NW 82ND AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1011
Practice Address - Country:US
Practice Address - Phone:786-420-5924
Practice Address - Fax:786-542-5340
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health