Provider Demographics
NPI:1134455231
Name:LISLE, KIM (MS)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:LISLE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 CLEARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-6316
Mailing Address - Country:US
Mailing Address - Phone:352-684-4250
Mailing Address - Fax:
Practice Address - Street 1:8132 KING HELIE BLVD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-1435
Practice Address - Country:US
Practice Address - Phone:727-834-3959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH7607101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health