Provider Demographics
NPI:1063798114
Name:PLUMMER, LISSETTE MERCEDES (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LISSETTE
Middle Name:MERCEDES
Last Name:PLUMMER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9601 SW 142ND AVE
Mailing Address - Street 2:706
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-7327
Mailing Address - Country:US
Mailing Address - Phone:305-804-5097
Mailing Address - Fax:
Practice Address - Street 1:9601 SW 142ND AVE
Practice Address - Street 2:706
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-7327
Practice Address - Country:US
Practice Address - Phone:305-804-5097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11924235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004338700Medicaid