Provider Demographics
NPI:1659826659
Name:RIERA, LISETTE D (PSY S,)
Entity Type:Individual
Prefix:
First Name:LISETTE
Middle Name:D
Last Name:RIERA
Suffix:
Gender:F
Credentials:PSY S,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11450 SW 105TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-3129
Mailing Address - Country:US
Mailing Address - Phone:786-255-3752
Mailing Address - Fax:
Practice Address - Street 1:15192 SW 137TH ST STE 13
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-5786
Practice Address - Country:US
Practice Address - Phone:786-529-8378
Practice Address - Fax:786-400-2134
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1246103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13878294OtherCAQH
FL018914800Medicaid