Provider Demographics
NPI:1922544386
Name:MESA, LIZANDRA
Entity Type:Individual
Prefix:
First Name:LIZANDRA
Middle Name:
Last Name:MESA
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 1:4163 SW 67TH AVE APT 215C
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-3220
Mailing Address - Country:US
Mailing Address - Phone:305-970-6117
Mailing Address - Fax:
Practice Address - Street 1:2100 W 76TH ST # 21
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5539
Practice Address - Country:US
Practice Address - Phone:305-557-1286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician