Provider Demographics
NPI:1629405881
Name:LISO, DANIELLE ROSE (PHD, BCBA-D)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:ROSE
Last Name:LISO
Suffix:
Gender:F
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4393 PEBBLE BROOK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-5661
Mailing Address - Country:US
Mailing Address - Phone:386-214-4868
Mailing Address - Fax:
Practice Address - Street 1:6867 SOUTHPOINT DR N
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8043
Practice Address - Country:US
Practice Address - Phone:904-619-6071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-05-2316103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst