=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649976986
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA REIDY PH.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2023
-----------------------------------------------------
Last Update Date | 02/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 NW 10TH AVE RM 7084
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33136-1015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-243-1337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2479 SW 23RD TER
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33145-3609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-979-8652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083T0002X
-----------------------------------------------------
Taxonomy Name | Medical Toxicology (Preventive Medicine) Physician
-----------------------------------------------------
License Number | DI44571
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------