Provider Demographics
NPI:1578828695
Name:JIMENEZ-CANO, LISSETTE RAFAELINA (MSED)
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:RAFAELINA
Last Name:JIMENEZ-CANO
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-4306
Mailing Address - Country:US
Mailing Address - Phone:718-919-6531
Mailing Address - Fax:
Practice Address - Street 1:31 PALMETTO ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-4306
Practice Address - Country:US
Practice Address - Phone:718-919-6531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency