Provider Demographics
NPI:1063114999
Name:BERMEO LAZO, RAYSA M
Entity type:Individual
Prefix:
First Name:RAYSA
Middle Name:M
Last Name:BERMEO LAZO
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 1:4300 SHERIDAN ST APT 201
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-3503
Mailing Address - Country:US
Mailing Address - Phone:754-423-3366
Mailing Address - Fax:
Practice Address - Street 1:4300 SHERIDAN ST APT 201
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3503
Practice Address - Country:US
Practice Address - Phone:754-423-3366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician