Provider Demographics
NPI:1861126344
Name:GIL, LISSETTE
Entity type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:GIL
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 1:3514 W 76TH ST UNIT 203
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-2702
Mailing Address - Country:US
Mailing Address - Phone:786-290-0792
Mailing Address - Fax:
Practice Address - Street 1:13501 SW 136TH ST STE 212
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-8321
Practice Address - Country:US
Practice Address - Phone:786-592-2004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-77189106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty