Healthcare Provider Details

I. General information

NPI: 1265276000
Provider Name (Legal Business Name): LISBET ROQUE PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 06/25/2024
Certification Date: 06/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3466 ARTESIAN DR
LAKE WORTH FL
33462-3614
US

IV. Provider business mailing address

3466 ARTESIAN DR
LAKE WORTH FL
33462-3614
US

V. Phone/Fax

Practice location:
  • Phone: 214-466-9479
  • Fax:
Mailing address:
  • Phone: 214-466-9479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: