Provider Demographics
NPI:1376903484
Name:VICENTE, LISA CHRISTINE (CASAC-T)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CHRISTINE
Last Name:VICENTE
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 E 119TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-3627
Mailing Address - Country:US
Mailing Address - Phone:212-360-4002
Mailing Address - Fax:212-360-4012
Practice Address - Street 1:435 E 119TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-3627
Practice Address - Country:US
Practice Address - Phone:212-360-4002
Practice Address - Fax:212-360-4012
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29072101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)