Provider Demographics
NPI:1891061271
Name:RUSSA, LISSETH (MS, RMHI, CBHCMS)
Entity Type:Individual
Prefix:MRS
First Name:LISSETH
Middle Name:
Last Name:RUSSA
Suffix:
Gender:F
Credentials:MS, RMHI, CBHCMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8228 LOST LAKE DR.
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-1384
Mailing Address - Country:US
Mailing Address - Phone:862-754-7373
Mailing Address - Fax:
Practice Address - Street 1:225 S SWOOPE AVE STE 211
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5786
Practice Address - Country:US
Practice Address - Phone:407-622-0444
Practice Address - Fax:407-699-0444
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH15818101YM0800X
104100000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIMH15818OtherDOH