Provider Demographics
NPI:1063160042
Name:LOMBERA, IVETTE SR
Entity type:Individual
Prefix:
First Name:IVETTE
Middle Name:
Last Name:LOMBERA
Suffix:SR
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 1:12864 SW 52ND ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-5836
Mailing Address - Country:US
Mailing Address - Phone:786-521-6976
Mailing Address - Fax:
Practice Address - Street 1:12864 SW 52ND ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-5836
Practice Address - Country:US
Practice Address - Phone:786-521-6976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-123959106S00000X
FL20123959106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician