Provider Demographics
NPI:1255899852
Name:REO, LISA M (LCPC, PMH)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:REO
Suffix:
Gender:F
Credentials:LCPC, PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 DELTONA BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-8016
Mailing Address - Country:US
Mailing Address - Phone:386-259-5413
Mailing Address - Fax:386-753-9265
Practice Address - Street 1:1052 RIVER WIND CIRCLE
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34212
Practice Address - Country:US
Practice Address - Phone:443-521-3685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1622101YM0800X
MDLC8497101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000OtherMENTAL HEALTH
FL1467691873Medicaid