Provider Demographics
NPI:1235592320
Name:LISS, MITCHELL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:LISS
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 1:1101 KINGS HWY N STE 313
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1912
Mailing Address - Country:US
Mailing Address - Phone:215-869-8195
Mailing Address - Fax:
Practice Address - Street 1:1101 KINGS HWY N STE 313
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1912
Practice Address - Country:US
Practice Address - Phone:215-869-8195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017309103TC0700X, 103TC2200X
NJ35SI00511900103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical