Provider Demographics
NPI:1528741840
Name:GONZALEZ DIAZ, LAZARO ADONYS
Entity type:Individual
Prefix:
First Name:LAZARO
Middle Name:ADONYS
Last Name:GONZALEZ DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9771 MARLIN RD
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-8739
Mailing Address - Country:US
Mailing Address - Phone:918-896-3802
Mailing Address - Fax:
Practice Address - Street 1:9771 MARLIN RD
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-8739
Practice Address - Country:US
Practice Address - Phone:918-896-3802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-290328106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician