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General NPI Number Information
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NPI Number | 1912384546
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Entity Type | Individual
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Provider Name | LISETTE FUNDORA LPC, LMHC
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Gender | Female
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Dates
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Enumeration Date | 05/04/2015
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Last Update Date | 01/01/2025
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Provider Practice Location Address
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Address Line | ONE COLUMBUS CENTER SUITE 600
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City | VIRGINIA BEACH
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State | VA
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Zip | 23462
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Country | US
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Telephone | 757-204-1230
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Fax |
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Provider Business Mailing Address
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Address Line | ONE COLUMBUS CENTER SUITE 600
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City | VIRGINIA BEACH
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State | VA
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Zip | 23462
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Country | US
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Telephone | 757-204-1230
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH15060
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701008466
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License Number State | VA
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