Provider Demographics
NPI:1538640610
Name:MIKLOSI, LISA (RBT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:MIKLOSI
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 BONNEAU ST
Mailing Address - Street 2:
Mailing Address - City:BONNEAU
Mailing Address - State:SC
Mailing Address - Zip Code:29431-8625
Mailing Address - Country:US
Mailing Address - Phone:843-810-6739
Mailing Address - Fax:
Practice Address - Street 1:408 BONNEAU ST
Practice Address - Street 2:
Practice Address - City:BONNEAU
Practice Address - State:SC
Practice Address - Zip Code:29431-8625
Practice Address - Country:US
Practice Address - Phone:843-810-6739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-18-55430106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician