Provider Demographics
NPI:1285823450
Name:PROULX, LISA (CPE)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PROULX
Suffix:
Gender:F
Credentials:CPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-1919
Mailing Address - Fax:
Practice Address - Street 1:711 TROY SCHENECTADY RD
Practice Address - Street 2:SUITE 212
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2442
Practice Address - Country:US
Practice Address - Phone:518-782-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150424174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist