Provider Demographics
NPI:1326269358
Name:PARK, LISA LYNN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:LYNN
Last Name:PARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 DEANS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-2616
Mailing Address - Country:US
Mailing Address - Phone:845-617-3076
Mailing Address - Fax:
Practice Address - Street 1:1938 ROUTE 6
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-2311
Practice Address - Country:US
Practice Address - Phone:845-225-5650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074430-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker