Provider Demographics
NPI:1194474114
Name:GAMBOA HERNANDEZ, LISANDRA (RBT)
Entity type:Individual
Prefix:
First Name:LISANDRA
Middle Name:
Last Name:GAMBOA HERNANDEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4360 SW 108TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-4850
Mailing Address - Country:US
Mailing Address - Phone:786-484-4116
Mailing Address - Fax:
Practice Address - Street 1:4360 SW 108TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-4850
Practice Address - Country:US
Practice Address - Phone:786-484-4116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician