Provider Demographics
NPI:1215203914
Name:LISTER, MICHAEL BRUCE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRUCE
Last Name:LISTER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 E MAIN ST
Mailing Address - Street 2:#3
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-6940
Mailing Address - Country:US
Mailing Address - Phone:607-754-1101
Mailing Address - Fax:607-754-1107
Practice Address - Street 1:423 E MAIN ST
Practice Address - Street 2:#2
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-6940
Practice Address - Country:US
Practice Address - Phone:607-754-1101
Practice Address - Fax:607-754-1107
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004531103TC0700X, 103TA0700X
NY021193-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging