Provider Demographics
NPI:1902502347
Name:FUNG COLLAZO, THALIA MUK LAM
Entity type:Individual
Prefix:
First Name:THALIA
Middle Name:MUK LAM
Last Name:FUNG COLLAZO
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 1:11530 SW 109TH RD APT X
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-3361
Mailing Address - Country:US
Mailing Address - Phone:248-550-9841
Mailing Address - Fax:
Practice Address - Street 1:12485 SW 137TH AVE STE 106
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4215
Practice Address - Country:US
Practice Address - Phone:786-250-4423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-24-77685103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician