Healthcare Provider Details

I. General information

NPI: 1629405881
Provider Name (Legal Business Name): DANIELLE ROSE LISO PHD., BCBA-D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6867 SOUTHPOINT DR N SUITE 101
JACKSONVILLE FL
32216-8043
US

IV. Provider business mailing address

4393 PEBBLE BROOK DR
JACKSONVILLE FL
32224-5661
US

V. Phone/Fax

Practice location:
  • Phone: 904-619-6071
  • Fax:
Mailing address:
  • Phone: 386-214-4868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-05-2316
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: