MEDICARE: MRS. LISETTE MIRA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker
2	101YM0800X	Mental Health Counselor	SW12313	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558694737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISETTE MIRA LCSW

Provider Business Mailing Address
First Line	:	700 S ROYAL POINCIANA BLVD STE 300
Second Line	:
City	:	MIAMI SPRINGS
State	:	FL
Zip	:	33166-6667
Country	:	US
Telephone Number	:	305-688-9000
Fax Number	:	305-662-1788

Provider Business Practice Location Address
First Line	:	700 S ROYAL POINCIANA BLVD STE 300
Second Line	:
City	:	MIAMI SPRINGS
State	:	FL
Zip	:	33166-6667
Country	:	US
Telephone Number	:	305-668-9000
Fax Number	:	305-662-1788

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2009
Last Update Date	:	03/15/2016

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