Provider Demographics
NPI:1194484626
Name:BOZA RODRIGUEZ, OLGA LIDIA
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:LIDIA
Last Name:BOZA 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 1:3669 SW 154TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4787
Mailing Address - Country:US
Mailing Address - Phone:786-585-2847
Mailing Address - Fax:
Practice Address - Street 1:3669 SW 154TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-4787
Practice Address - Country:US
Practice Address - Phone:786-585-2847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1Medicaid