Provider Demographics
NPI:1225863350
Name:BACALLAO NAVARRO, LISET
Entity type:Individual
Prefix:
First Name:LISET
Middle Name:
Last Name:BACALLAO NAVARRO
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 1:2708 PRAIRIE LN
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33406-6760
Mailing Address - Country:US
Mailing Address - Phone:728-206-2620
Mailing Address - Fax:
Practice Address - Street 1:2708 PRAIRIE LN
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33406-6760
Practice Address - Country:US
Practice Address - Phone:728-206-2620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician