Provider Demographics
NPI:1285292938
Name:LORA, GERTRUDIS IVELISSE
Entity type:Individual
Prefix:
First Name:GERTRUDIS
Middle Name:IVELISSE
Last Name:LORA
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 1:15332 SW 43RD CT
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-3388
Mailing Address - Country:US
Mailing Address - Phone:954-699-1349
Mailing Address - Fax:
Practice Address - Street 1:15332 SW 43RD CT
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-3388
Practice Address - Country:US
Practice Address - Phone:954-699-1349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty