=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861126344
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISSETTE GIL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2022
-----------------------------------------------------
Last Update Date | 07/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13501 SW 136TH ST STE 212
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-8321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-592-2004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3514 W 76TH ST UNIT 203
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33018-2702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-290-0792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-19-77189
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------