Provider Demographics
NPI:1518352806
Name:FISSE-REPOLE, HEATHER (LMHC, LMT)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:FISSE-REPOLE
Suffix:
Gender:F
Credentials:LMHC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9957 MOORINGS DR
Mailing Address - Street 2:STE. 403
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-2412
Mailing Address - Country:US
Mailing Address - Phone:904-268-6568
Mailing Address - Fax:904-886-9804
Practice Address - Street 1:9957 MOORINGS DR
Practice Address - Street 2:STE. 403
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-2412
Practice Address - Country:US
Practice Address - Phone:904-268-6568
Practice Address - Fax:904-886-9804
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13170101YM0800X
FLMA53350225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist