Provider Demographics
NPI:1780400127
Name:VELAZQUEZ DIEGUEZ, LISBET
Entity type:Individual
Prefix:
First Name:LISBET
Middle Name:
Last Name:VELAZQUEZ DIEGUEZ
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 1:1670 LAUREL ST APT 105
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-6858
Mailing Address - Country:US
Mailing Address - Phone:502-915-6361
Mailing Address - Fax:
Practice Address - Street 1:4418 5TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-1531
Practice Address - Country:US
Practice Address - Phone:727-224-5301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-395989106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician