Provider Demographics
NPI:1043563539
Name:GEFEN, LISA (MS ED)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:GEFEN
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 BAY 28TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1413 BAY 28TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1703
Practice Address - Country:US
Practice Address - Phone:718-868-3130
Practice Address - Fax:718-868-3130
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-21
Last Update Date:2012-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY481347041252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency