Provider Demographics
NPI:1265240881
Name:FLEITES GUEVARA, LISA MARY
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARY
Last Name:FLEITES GUEVARA
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 1:1860 FERN RD
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-6418
Mailing Address - Country:US
Mailing Address - Phone:954-520-5096
Mailing Address - Fax:
Practice Address - Street 1:1860 FERN RD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-6418
Practice Address - Country:US
Practice Address - Phone:954-520-5096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-28
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-342509106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician