Provider Demographics
NPI:1316102114
Name:CICETTI, LISA (PSYD,LMHC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CICETTI
Suffix:
Gender:F
Credentials:PSYD,LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 NEPTUNE DR
Mailing Address - Street 2:
Mailing Address - City:HYPOLUXO
Mailing Address - State:FL
Mailing Address - Zip Code:33462-6019
Mailing Address - Country:US
Mailing Address - Phone:561-734-6118
Mailing Address - Fax:561-369-3275
Practice Address - Street 1:2500 QUANTUM LAKES DR STE 203
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-8323
Practice Address - Country:US
Practice Address - Phone:561-502-1992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 6095101YM0800X
103T00000X
FLPY 7715103TB0200X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684466996Medicaid