Provider Demographics
NPI:1588911648
Name:MIRANDA, LAZARO R (BS)
Entity type:Individual
Prefix:
First Name:LAZARO
Middle Name:R
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1471 NW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-3823
Mailing Address - Country:US
Mailing Address - Phone:786-571-3231
Mailing Address - Fax:
Practice Address - Street 1:1471 NW 10TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030
Practice Address - Country:US
Practice Address - Phone:786-571-3231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X, 171M00000X
FL55023106S00000X
FL0-21-13273106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCBHCMS100704OtherFLORIDA CERTIFICATION BOARD
0-21-13273OtherBEHAVIOR ANALYST CERTIFICATION BOARD