Provider Demographics
NPI:1275053647
Name:LIA, JESSICA ELIZABETH (ATR-BC, LCAT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:LIA
Suffix:
Gender:F
Credentials:ATR-BC, LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 PARK AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-1839
Mailing Address - Country:US
Mailing Address - Phone:516-320-3140
Mailing Address - Fax:
Practice Address - Street 1:1438 PARK AVE APT 1
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-1839
Practice Address - Country:US
Practice Address - Phone:516-320-3140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002291221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist