Healthcare Provider Details

I. General information

NPI: 1891391009
Provider Name (Legal Business Name): LISETTE HARRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1765 SW CAPTAINS PL
PALM CITY FL
34990-1747
US

IV. Provider business mailing address

59 SHORT BRANCH DR
RANSON WV
25438-4618
US

V. Phone/Fax

Practice location:
  • Phone: 772-266-8727
  • Fax: 772-494-7093
Mailing address:
  • Phone: 304-707-1468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-536538
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: