Provider Demographics
NPI:1861718975
Name:CARMONA-ROMAN, LISSETTE (PSYD)
Entity type:Individual
Prefix:DR
First Name:LISSETTE
Middle Name:
Last Name:CARMONA-ROMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LISSETTE
Other - Middle Name:
Other - Last Name:CARMONA CAMACHO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISSETTE CARMONA
Mailing Address - Street 1:521 BRUNSWICK DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-4609
Mailing Address - Country:US
Mailing Address - Phone:347-480-6490
Mailing Address - Fax:
Practice Address - Street 1:521 BRUNSWICK DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-4609
Practice Address - Country:US
Practice Address - Phone:347-480-6490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3509103T00000X
390200000X
FLPY11323103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program