Provider Demographics
NPI:1619547494
Name:KOSS, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KOSS
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 1:120 ACKLINS CIR APT 312
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32119-9762
Mailing Address - Country:US
Mailing Address - Phone:954-471-6075
Mailing Address - Fax:
Practice Address - Street 1:120 ACKLINS CIR APT 312
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32119-9762
Practice Address - Country:US
Practice Address - Phone:954-471-6075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH19399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health