Provider Demographics
NPI:1447761648
Name:DEJESUS, LIZ S (RN)
Entity Type:Individual
Prefix:MRS
First Name:LIZ
Middle Name:S
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HIGH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STONY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10980-2710
Mailing Address - Country:US
Mailing Address - Phone:646-271-0750
Mailing Address - Fax:
Practice Address - Street 1:706 EXECUTIVE BLVD STE D
Practice Address - Street 2:
Practice Address - City:VALLEY COTTAGE
Practice Address - State:NY
Practice Address - Zip Code:10989-2039
Practice Address - Country:US
Practice Address - Phone:845-362-3904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY703033261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone