Provider Demographics
NPI:1033876016
Name:GANZ, LISA DERITIS
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DERITIS
Last Name:GANZ
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 1:46 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-3957
Mailing Address - Country:US
Mailing Address - Phone:607-727-9130
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD COUNTRY RD STE C103N
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5156
Practice Address - Country:US
Practice Address - Phone:516-806-6969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2854054103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool