Provider Demographics
NPI:1306140520
Name:DISU, DISHAUN (LMHC)
Entity type:Individual
Prefix:MRS
First Name:DISHAUN
Middle Name:
Last Name:DISU
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 1:10245 MAGNOLIA HILLS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-4993
Mailing Address - Country:US
Mailing Address - Phone:904-444-8260
Mailing Address - Fax:904-269-0499
Practice Address - Street 1:7530 103RD ST STE 12
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-6786
Practice Address - Country:US
Practice Address - Phone:904-444-8260
Practice Address - Fax:904-574-9449
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10580101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029591400Medicaid