Provider Demographics
NPI:1124866009
Name:VIZCAINO DOMINGUEZ, LIS LIEN
Entity type:Individual
Prefix:
First Name:LIS LIEN
Middle Name:
Last Name:VIZCAINO DOMINGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-4740
Mailing Address - Country:US
Mailing Address - Phone:407-748-8020
Mailing Address - Fax:
Practice Address - Street 1:1513 ORANGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4740
Practice Address - Country:US
Practice Address - Phone:407-748-8020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL243600629106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician