Provider Demographics
NPI:1639670482
Name:FONTE VASALLO, LISLIET
Entity Type:Individual
Prefix:
First Name:LISLIET
Middle Name:
Last Name:FONTE VASALLO
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 1:12262 SW 214TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-5967
Mailing Address - Country:US
Mailing Address - Phone:503-619-5658
Mailing Address - Fax:
Practice Address - Street 1:7530 SUNSET DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4132
Practice Address - Country:US
Practice Address - Phone:305-271-8790
Practice Address - Fax:305-271-8789
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician