Provider Demographics
NPI:1265028039
Name:AGUIRRE, LISSETTE
Entity type:Individual
Prefix:MS
First Name:LISSETTE
Middle Name:
Last Name:AGUIRRE
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 1:12315 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2434
Mailing Address - Country:US
Mailing Address - Phone:786-930-0115
Mailing Address - Fax:
Practice Address - Street 1:13301 SW 132ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6188
Practice Address - Country:US
Practice Address - Phone:786-713-5553
Practice Address - Fax:786-713-5559
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1Medicaid