Provider Demographics
NPI:1235718073
Name:CONSUEGRA LARGO, LISANDRA
Entity Type:Individual
Prefix:
First Name:LISANDRA
Middle Name:
Last Name:CONSUEGRA LARGO
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 1:198 TROPICAL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-1944
Mailing Address - Country:US
Mailing Address - Phone:561-729-8483
Mailing Address - Fax:
Practice Address - Street 1:2240 PALM BCH LK BLVD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-3410
Practice Address - Country:US
Practice Address - Phone:561-429-5919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20144386106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician