Provider Demographics
NPI:1235714486
Name:FORESTAL, LISSA
Entity type:Individual
Prefix:
First Name:LISSA
Middle Name:
Last Name:FORESTAL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 SW FINCH LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1568
Mailing Address - Country:US
Mailing Address - Phone:772-626-2198
Mailing Address - Fax:
Practice Address - Street 1:1701 SW FINCH LN
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1568
Practice Address - Country:US
Practice Address - Phone:772-626-2198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst