Provider Demographics
NPI:1396829297
Name:MCDERMOTT, LISA (CSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E GENESEE ST
Mailing Address - Street 2:217
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3130
Mailing Address - Country:US
Mailing Address - Phone:315-422-0300
Mailing Address - Fax:315-479-8455
Practice Address - Street 1:600 E GENESEE ST
Practice Address - Street 2:217
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3130
Practice Address - Country:US
Practice Address - Phone:315-422-0300
Practice Address - Fax:315-479-8455
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR039562-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC7419Medicare ID - Type Unspecified