Healthcare Provider Details

I. General information

NPI: 1497417802
Provider Name (Legal Business Name): LISA OBRADOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 07/19/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N ROME AVE #4127
TAMPA FL
33606
US

IV. Provider business mailing address

401 N ROME AVE APT 4127
TAMPA FL
33606-0043
US

V. Phone/Fax

Practice location:
  • Phone: 813-421-1609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: