Provider Demographics
NPI:1003585837
Name:BRANDER, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRANDER
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 1:405 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11768
Mailing Address - Country:US
Mailing Address - Phone:631-868-1244
Mailing Address - Fax:631-567-1648
Practice Address - Street 1:405 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1695
Practice Address - Country:US
Practice Address - Phone:631-868-1244
Practice Address - Fax:631-567-1648
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical