Provider Demographics
NPI:1508450164
Name:LISEWSKI, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LISEWSKI
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 1:2 MUNSSEE CT
Mailing Address - Street 2:
Mailing Address - City:STONY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10980-3440
Mailing Address - Country:US
Mailing Address - Phone:845-802-1023
Mailing Address - Fax:
Practice Address - Street 1:2 MUNSSEE CT
Practice Address - Street 2:
Practice Address - City:STONY POINT
Practice Address - State:NY
Practice Address - Zip Code:10980-3440
Practice Address - Country:US
Practice Address - Phone:845-802-1023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025430225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty