Healthcare Provider Details

I. General information

NPI: 1619589439
Provider Name (Legal Business Name): LISANDRA MOYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29731 MORWEN PL
WESLEY CHAPEL FL
33543-6738
US

IV. Provider business mailing address

29731 MORWEN PL
WESLEY CHAPEL FL
33543-6738
US

V. Phone/Fax

Practice location:
  • Phone: 352-345-7950
  • Fax:
Mailing address:
  • Phone: 352-345-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-132168
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: