Healthcare Provider Details

I. General information

NPI: 1780987529
Provider Name (Legal Business Name): MRS. LISA UPSHAW FUENTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 12TH AVE N
SAFETY HARBOR FL
34695-3420
US

IV. Provider business mailing address

140 12TH AVE N
SAFETY HARBOR FL
34695-3420
US

V. Phone/Fax

Practice location:
  • Phone: 631-561-8709
  • Fax:
Mailing address:
  • Phone: 631-561-8709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: