Healthcare Provider Details

I. General information

NPI: 1619804614
Provider Name (Legal Business Name): LISANDRA GAMEZ GARCIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 S VINEYARD STE 123
MESA AZ
85210-6893
US

IV. Provider business mailing address

4336 N 35TH AVE APT 148
PHOENIX AZ
85017-3895
US

V. Phone/Fax

Practice location:
  • Phone: 480-656-3530
  • Fax:
Mailing address:
  • Phone: 602-369-0560
  • Fax: 602-369-0560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: