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General NPI Number Information
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NPI Number | 1639124100
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Entity Type | Individual
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Provider Name | VICTORIA DE LISSOVOY LCSW
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Gender | Female
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 06/04/2008
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Provider Practice Location Address
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Address Line | 1109 BRYN MAWR AVE
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City | LAKE WALES
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State | FL
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Zip | 33853-4333
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Country | US
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Telephone | 863-605-1865
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Fax |
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Provider Business Mailing Address
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Address Line | 6253 N LANTANA DR PO BOX 7037
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City | INDIAN LAKE ESTATES
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State | FL
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Zip | 33855-7037
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Country | US
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Telephone | 863-605-1865
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW6807
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License Number State | FL
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