Provider Demographics
NPI:1427203736
Name:PROVENZANO, LIZA CRISTIN (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:LIZA
Middle Name:CRISTIN
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 COLLINSWOOD DR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-0861
Mailing Address - Country:US
Mailing Address - Phone:904-568-5826
Mailing Address - Fax:
Practice Address - Street 1:13400 SUTTON PARK DR S
Practice Address - Street 2:SUITE 1504
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-0236
Practice Address - Country:US
Practice Address - Phone:904-568-5826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9038101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health