Provider Demographics
NPI:1043290190
Name:PREDMORE, LISA CAROLINE (AUD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CAROLINE
Last Name:PREDMORE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 NORTHERN BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3048
Mailing Address - Country:US
Mailing Address - Phone:516-627-7600
Mailing Address - Fax:516-627-6378
Practice Address - Street 1:1165 NORTHERN BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3048
Practice Address - Country:US
Practice Address - Phone:516-627-7600
Practice Address - Fax:516-627-6378
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001204231H00000X, 332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02266580Medicaid
NY02266580Medicaid
NYR45307Medicare UPIN