Provider Demographics
NPI:1275060618
Name:BURGOS REGALADO, LISET
Entity type:Individual
Prefix:
First Name:LISET
Middle Name:
Last Name:BURGOS REGALADO
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 1:5450 NW 168TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-3969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5450 NW 168TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-3969
Practice Address - Country:US
Practice Address - Phone:786-506-6680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-16
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH24701101YM0800X
247200000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician