Provider Demographics
NPI:1285488692
Name:CORVO, LAZARO JESUS (RBT)
Entity type:Individual
Prefix:
First Name:LAZARO
Middle Name:JESUS
Last Name:CORVO
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12511 SW 12TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2387
Mailing Address - Country:US
Mailing Address - Phone:786-312-7751
Mailing Address - Fax:
Practice Address - Street 1:2500 SW 107TH AVE STE 37
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-2425
Practice Address - Country:US
Practice Address - Phone:305-228-3780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC612-530-75-218-1106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician