Provider Demographics
NPI:1104597608
Name:NOVO GARCIA, LISANDRA DE LOS ANGELES
Entity type:Individual
Prefix:
First Name:LISANDRA
Middle Name:DE LOS ANGELES
Last Name:NOVO GARCIA
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 1:10217 SW 24TH ST APT A111
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-2503
Mailing Address - Country:US
Mailing Address - Phone:305-988-9210
Mailing Address - Fax:
Practice Address - Street 1:10217 SW 24TH ST APT A111
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-2503
Practice Address - Country:US
Practice Address - Phone:305-988-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-125788106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician