Provider Demographics
NPI:1861918393
Name:GAMBOA, LISSETTE (LMHC, BCBA)
Entity type:Individual
Prefix:MRS
First Name:LISSETTE
Middle Name:
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:LMHC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5437 SW 132ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-5432
Mailing Address - Country:US
Mailing Address - Phone:305-494-1902
Mailing Address - Fax:
Practice Address - Street 1:13195 SW 134TH ST STE 201
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4585
Practice Address - Country:US
Practice Address - Phone:786-206-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15245101YM0800X
FL1-20-41535103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health