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Individual

MRS. LISSETH RUSSA

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
F
Credential
MS, RMHI, CBHCMS

Contact information

Practice address
225 S SWOOPE AVE STE 211, MAITLAND, FL 32751-5786
(407) 622-0444
(407) 699-0444
Mailing address
8228 LOST LAKE DR., ORLANDO, FL 32817-1384
(862) 754-7373

Taxonomy

Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
IMH15818
FL
104100000X
Social Worker
171M00000X
Case Manager/Care Coordinator
Primary

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
IMH15818
DOH
FL
Enumeration date
03/29/2012
Last updated
03/17/2018
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