Provider Demographics
NPI:1396392528
Name:VIVO, LISA MAGALY (EDS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MAGALY
Last Name:VIVO
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 TATTENHAM WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6512
Mailing Address - Country:US
Mailing Address - Phone:813-468-6642
Mailing Address - Fax:
Practice Address - Street 1:1121 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-3727
Practice Address - Country:US
Practice Address - Phone:407-929-7399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1276103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool