Provider Demographics
NPI:1124325840
Name:MUNIZ, LISSETTE (LMHC)
Entity type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:MUNIZ
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18801 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4980
Mailing Address - Country:US
Mailing Address - Phone:813-438-2120
Mailing Address - Fax:
Practice Address - Street 1:11806 BRUCE B DOWNS BLVD
Practice Address - Street 2:#1003
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:813-438-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17225101YM0800X
1041C0700X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid