Healthcare Provider Details

I. General information

NPI: 1912401068
Provider Name (Legal Business Name): LISA MARIE LYNN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. LISA MARIE JACQUES-QUINTANA

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 SW 74TH AVE STE C2
OCALA FL
34474-7214
US

IV. Provider business mailing address

9 NEEDLES DR
OCALA FL
34482-3506
US

V. Phone/Fax

Practice location:
  • Phone: 352-454-8950
  • Fax:
Mailing address:
  • Phone: 352-454-8950
  • Fax: 352-873-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH12252
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12252
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: