Provider Demographics
NPI:1205598869
Name:ROSELL HERRADA, LISNET
Entity type:Individual
Prefix:
First Name:LISNET
Middle Name:
Last Name:ROSELL HERRADA
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 1:15133 NW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1800
Mailing Address - Country:US
Mailing Address - Phone:305-833-8477
Mailing Address - Fax:
Practice Address - Street 1:15133 NW 1ST ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1800
Practice Address - Country:US
Practice Address - Phone:305-833-8477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-70680106S00000X
FL1-21-57369103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician