Provider Demographics
NPI:1053042697
Name:FUENTES MARTINEZ, LISANDRA TIHANNY
Entity Type:Individual
Prefix:
First Name:LISANDRA
Middle Name:TIHANNY
Last Name:FUENTES MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 NW 101ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33147-1528
Mailing Address - Country:US
Mailing Address - Phone:786-908-3007
Mailing Address - Fax:
Practice Address - Street 1:3620 NW 101ST ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33147-1528
Practice Address - Country:US
Practice Address - Phone:786-908-3007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-111643106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician