Provider Demographics
NPI:1346742129
Name:HOMER-DAVIS, LISE-MARIE (MS, LMFT)
Entity type:Individual
Prefix:MISS
First Name:LISE-MARIE
Middle Name:
Last Name:HOMER-DAVIS
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 S UNIVERSITY DR STE 292
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3308
Mailing Address - Country:US
Mailing Address - Phone:954-579-4096
Mailing Address - Fax:
Practice Address - Street 1:292 S UNIVERSITY DR STE 292
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3308
Practice Address - Country:US
Practice Address - Phone:954-579-4096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4195106H00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist