Provider Demographics
NPI:1073160412
Name:BURDISH, ALISA M
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:M
Last Name:BURDISH
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 GARFIELD PL
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-5921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:229 LAUREL RD
Practice Address - Street 2:
Practice Address - City:E NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-1118
Practice Address - Country:US
Practice Address - Phone:631-659-3337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1339219191252Y00000X
NY1338638191252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency