Provider Demographics
NPI:1558143586
Name:CANCHO, LYSMAR KARINA I
Entity Type:Individual
Prefix:MS
First Name:LYSMAR
Middle Name:KARINA
Last Name:CANCHO
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 COMMERCIAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-6569
Mailing Address - Country:US
Mailing Address - Phone:863-345-8090
Mailing Address - Fax:863-606-0146
Practice Address - Street 1:1510 COMMERCIAL PARK DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-6569
Practice Address - Country:US
Practice Address - Phone:863-345-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)