Provider Demographics
NPI:1043753874
Name:LISA M. CASSIDY, PSYCHOLOGY, P.C.
Entity Type:Organization
Organization Name:LISA M. CASSIDY, PSYCHOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CASSIDY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:631-748-4659
Mailing Address - Street 1:4250 VETS HWY
Mailing Address - Street 2:SUITE 215
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4000
Mailing Address - Country:US
Mailing Address - Phone:631-748-4659
Mailing Address - Fax:
Practice Address - Street 1:4250 VETS HWY
Practice Address - Street 2:SUITE 215
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4000
Practice Address - Country:US
Practice Address - Phone:631-748-4659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011578305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1396287835OtherPRIVATE NPI NUMBER