Provider Demographics
NPI:1417206889
Name:MCDALE, LISA M (MSED)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:MCDALE
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2126 UNION STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212
Mailing Address - Country:US
Mailing Address - Phone:917-808-9367
Mailing Address - Fax:
Practice Address - Street 1:2126 UNION STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212
Practice Address - Country:US
Practice Address - Phone:917-808-9367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2206871174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist