MEDICARE: DR. LISSETTE CARMONA-ROMAN PSYD

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	103T00000X	Psychologist	3509	PR
2	390200000X	Student in an Organized Health Care Education/Training Program
3	103T00000X	Psychologist	PY11323	FL

General Provider Information

NPI Number	:	1861718975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISSETTE CARMONA-ROMAN PSYD

Provider Business Mailing Address
First Line	:	521 BRUNSWICK DR
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33837-4609
Country	:	US
Telephone Number	:	347-480-6490
Fax Number	:

Provider Business Practice Location Address
First Line	:	521 BRUNSWICK DR
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33837-4609
Country	:	US
Telephone Number	:	347-480-6490
Fax Number	:

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

Provider Enumeration Date	:	04/14/2010
Last Update Date	:	11/14/2022

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