Provider Demographics
NPI:1295549798
Name:BLISSETT, CORNEISHA
Entity type:Individual
Prefix:
First Name:CORNEISHA
Middle Name:
Last Name:BLISSETT
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 1:2430 NE 8TH TER
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-6462
Mailing Address - Country:US
Mailing Address - Phone:229-488-6139
Mailing Address - Fax:
Practice Address - Street 1:1398 SW 160TH AVE STE 401
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33326-1905
Practice Address - Country:US
Practice Address - Phone:855-444-5664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5894101Y00000X
LA1234103TF0000X
AL987456A103TS0200X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool