Provider Demographics
NPI:1659182541
Name:SALA HERRERA, LISANDRA DE LAS MERCEDES
Entity type:Individual
Prefix:
First Name:LISANDRA
Middle Name:DE LAS MERCEDES
Last Name:SALA HERRERA
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 1:6321 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-4105
Mailing Address - Country:US
Mailing Address - Phone:727-565-6380
Mailing Address - Fax:
Practice Address - Street 1:6321 22ND AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-4105
Practice Address - Country:US
Practice Address - Phone:727-565-6380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-18
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24398957106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician