Provider Demographics
NPI:1497367783
Name:MIRABILE, LISA (LCAT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MIRABILE
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MAIDEN LN STE 1405
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-5113
Mailing Address - Country:US
Mailing Address - Phone:347-927-6896
Mailing Address - Fax:
Practice Address - Street 1:15 MAIDEN LN STE 1405
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-5113
Practice Address - Country:US
Practice Address - Phone:347-927-6896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002445-01221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist