Provider Demographics
NPI:1619448818
Name:ISMA, MARYSE IMBERT
Entity Type:Individual
Prefix:MRS
First Name:MARYSE
Middle Name:IMBERT
Last Name:ISMA
Suffix:
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 1:2425 DEN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3636
Mailing Address - Country:US
Mailing Address - Phone:954-649-0800
Mailing Address - Fax:
Practice Address - Street 1:2425 DEN ST
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3636
Practice Address - Country:US
Practice Address - Phone:954-649-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW11093106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst