Healthcare Provider Details

I. General information

NPI: 1255899852
Provider Name (Legal Business Name): LISA M REO LCPC, PMH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2019
Last Update Date: 07/29/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1052 RIVER WIND CIRCLE
BRADENTON FL
34212
US

IV. Provider business mailing address

517 DELTONA BLVD STE A
DELTONA FL
32725-8016
US

V. Phone/Fax

Practice location:
  • Phone: 443-521-3685
  • Fax:
Mailing address:
  • Phone: 386-259-5413
  • Fax: 386-753-9265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1622
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC8497
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: