Healthcare Provider Details

I. General information

NPI: 1669984225
Provider Name (Legal Business Name): LISANDRA PENA BARCELO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12140 SW 179TH TER
MIAMI FL
33177-2323
US

IV. Provider business mailing address

12140 SW 179TH TER
MIAMI FL
33177-2323
US

V. Phone/Fax

Practice location:
  • Phone: 305-562-7542
  • Fax:
Mailing address:
  • Phone: 305-562-7542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-78679
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: