Provider Demographics
NPI:1265643860
Name:WISEL, LISA MARIE (MS,ADTR-LCAT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:WISEL
Suffix:
Gender:F
Credentials:MS,ADTR-LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E BROADWAY
Mailing Address - Street 2:NUMBER 2T
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4446
Mailing Address - Country:US
Mailing Address - Phone:516-431-8788
Mailing Address - Fax:516-431-8788
Practice Address - Street 1:410 E BROADWAY
Practice Address - Street 2:NUMBER 2T
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-4446
Practice Address - Country:US
Practice Address - Phone:516-431-8788
Practice Address - Fax:516-431-8788
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000708174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist