Provider Demographics
NPI:1669948261
Name:DACKO, LISA SARKEES
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SARKEES
Last Name:DACKO
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 1:1558 MEADOW LARK DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7919
Mailing Address - Country:US
Mailing Address - Phone:321-501-1770
Mailing Address - Fax:
Practice Address - Street 1:220 BARTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2742
Practice Address - Country:US
Practice Address - Phone:321-241-6800
Practice Address - Fax:321-241-6890
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW139721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106729300Medicaid