Provider Demographics
NPI:1033995873
Name:WIATER, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WIATER
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 1:16 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-1476
Mailing Address - Country:US
Mailing Address - Phone:908-591-2813
Mailing Address - Fax:
Practice Address - Street 1:953 US HIGHWAY 202 N
Practice Address - Street 2:
Practice Address - City:BRANCHBURG
Practice Address - State:NJ
Practice Address - Zip Code:08876-3791
Practice Address - Country:US
Practice Address - Phone:908-356-5955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00729900106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist