Provider Demographics
NPI:1558694737
Name:MIRA, LISETTE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LISETTE
Middle Name:
Last Name:MIRA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S ROYAL POINCIANA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:MIAMI SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6667
Mailing Address - Country:US
Mailing Address - Phone:305-688-9000
Mailing Address - Fax:305-662-1788
Practice Address - Street 1:700 S ROYAL POINCIANA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:MIAMI SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33166-6667
Practice Address - Country:US
Practice Address - Phone:305-668-9000
Practice Address - Fax:305-662-1788
Is Sole Proprietor?:No
Enumeration Date:2009-09-07
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FLSW12313101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker