Provider Demographics
NPI:1053634014
Name:BAILEY, LISA D (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:BAILEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12412 SAN JOSE BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8620
Mailing Address - Country:US
Mailing Address - Phone:904-432-3321
Mailing Address - Fax:904-432-3324
Practice Address - Street 1:12412 SAN JOSE BLVD STE 203
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8620
Practice Address - Country:US
Practice Address - Phone:904-432-3321
Practice Address - Fax:904-432-3324
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9441103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIN066ZMedicare PIN
FLIN066YMedicare PIN