Provider Demographics
NPI:1093284036
Name:DE LIZ, THERESE MARIE
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:MARIE
Last Name:DE LIZ
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 1:2246 OSPREY AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6578
Mailing Address - Country:US
Mailing Address - Phone:407-864-0708
Mailing Address - Fax:
Practice Address - Street 1:2246 OSPREY AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6578
Practice Address - Country:US
Practice Address - Phone:407-864-0708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16509101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health