Healthcare Provider Details

I. General information

NPI: 1962982009
Provider Name (Legal Business Name): LISETTE BROCHAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29228 US HIGHWAY 19 N
CLEARWATER FL
33761-2101
US

IV. Provider business mailing address

175 MIDDLE ST UNIT 1201
LAKE MARY FL
32746-3625
US

V. Phone/Fax

Practice location:
  • Phone: 727-351-4191
  • Fax: 727-314-7288
Mailing address:
  • Phone: 866-610-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-47833
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: