=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831419340
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YULISSA FUNDORA LMHC, PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2010
-----------------------------------------------------
Last Update Date | 03/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11529 SW 13TH CT
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33025-4811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-378-0556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11529 SW 13TH CT
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33025-4811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-378-0556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH11719
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY10407
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------