Provider Demographics
NPI:1922780295
Name:ROBAYO PULGAR, LISSETH CAROLINA
Entity Type:Individual
Prefix:
First Name:LISSETH
Middle Name:CAROLINA
Last Name:ROBAYO PULGAR
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 1:6900 S ORANGE BLOSSOM TRL STE 400
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-5734
Mailing Address - Country:US
Mailing Address - Phone:407-602-7442
Mailing Address - Fax:786-631-4483
Practice Address - Street 1:6900 S ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-5745
Practice Address - Country:US
Practice Address - Phone:407-602-7442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB929575106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician