Provider Demographics
NPI:1104580588
Name:TEMES PARRAGA, LISSET YOLANDA
Entity type:Individual
Prefix:
First Name:LISSET
Middle Name:YOLANDA
Last Name:TEMES PARRAGA
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 1:2100 SPRINGDALE BLVD APT Y217
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-6368
Mailing Address - Country:US
Mailing Address - Phone:561-229-7164
Mailing Address - Fax:
Practice Address - Street 1:8461 LAKE WORTH RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2474
Practice Address - Country:US
Practice Address - Phone:561-315-4170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101511000Medicaid