Provider Demographics
NPI:1548039175
Name:ROSA, LORENA
Entity type:Individual
Prefix:
First Name:LORENA
Middle Name:
Last Name:ROSA
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 1:7201 MIAMI LAKES DR APT B16
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-6954
Mailing Address - Country:US
Mailing Address - Phone:786-499-9479
Mailing Address - Fax:
Practice Address - Street 1:7201 MIAMI LAKES DR APT B16
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-6954
Practice Address - Country:US
Practice Address - Phone:786-499-9479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23292348106S00000X
FL23-292348106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician