Provider Demographics
NPI:1215343033
Name:MAZZOTTI, LISA (LMHC, CAP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MAZZOTTI
Suffix:
Gender:F
Credentials:LMHC, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 COLONIAL BLVD STE B-1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907
Mailing Address - Country:US
Mailing Address - Phone:217-825-8664
Mailing Address - Fax:239-278-7785
Practice Address - Street 1:1700 EDUCATION AVE
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-6222
Practice Address - Country:US
Practice Address - Phone:941-639-8300
Practice Address - Fax:941-347-6455
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12675101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor