Provider Demographics
NPI:1477909265
Name:ROBB, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROBB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 COBB LN APT I
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-7045
Mailing Address - Country:US
Mailing Address - Phone:845-699-9040
Mailing Address - Fax:
Practice Address - Street 1:27 JAMES P KELLY WAY APT 22
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-9452
Practice Address - Country:US
Practice Address - Phone:845-699-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY725806132174400000X, 252Y00000X
NY106520-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No174400000XOther Service ProvidersSpecialist
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1477909265Medicaid