Provider Demographics
NPI:1366571762
Name:LIZARRAGA, AMIR
Entity type:Individual
Prefix:MR
First Name:AMIR
Middle Name:
Last Name:LIZARRAGA
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 1:101 HERITAGE CIR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-2703
Mailing Address - Country:US
Mailing Address - Phone:850-230-9831
Mailing Address - Fax:
Practice Address - Street 1:101 HERITAGE CIR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-2703
Practice Address - Country:US
Practice Address - Phone:850-230-9831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL06000104299251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services