Provider Demographics
NPI:1306411046
Name:LAFAURIE, JELISSA
Entity Type:Individual
Prefix:
First Name:JELISSA
Middle Name:
Last Name:LAFAURIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JELISSA
Other - Middle Name:
Other - Last Name:LAFAURIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13711 SW 84TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-4087
Mailing Address - Country:US
Mailing Address - Phone:786-266-4182
Mailing Address - Fax:
Practice Address - Street 1:13711 SW 84TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-4087
Practice Address - Country:US
Practice Address - Phone:786-266-4182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-155762106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-21-155762Medicaid