Provider Demographics
NPI:1376029561
Name:MCENALLY, LISSETTE IDA (ITFS)
Entity type:Individual
Prefix:MRS
First Name:LISSETTE
Middle Name:IDA
Last Name:MCENALLY
Suffix:
Gender:F
Credentials:ITFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 BROOKS AVE
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-3812
Mailing Address - Country:US
Mailing Address - Phone:919-819-1738
Mailing Address - Fax:
Practice Address - Street 1:911 BROOKS AVE
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-3812
Practice Address - Country:US
Practice Address - Phone:919-819-1738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist