Provider Demographics
NPI:1386013084
Name:MESA, LISSELOT T (COTA)
Entity Type:Individual
Prefix:
First Name:LISSELOT
Middle Name:T
Last Name:MESA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11055 SW 161ST TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-2840
Mailing Address - Country:US
Mailing Address - Phone:305-984-6080
Mailing Address - Fax:
Practice Address - Street 1:311 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4738
Practice Address - Country:US
Practice Address - Phone:305-248-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA14395251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health