Provider Demographics
NPI:1659494953
Name:PASS, LISA K (PH D)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:K
Last Name:PASS
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 E END AVE
Mailing Address - Street 2:APT 2A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-1192
Mailing Address - Country:US
Mailing Address - Phone:917-974-9150
Mailing Address - Fax:
Practice Address - Street 1:240 W 102ND ST
Practice Address - Street 2:SUITE 15
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-4900
Practice Address - Country:US
Practice Address - Phone:917-974-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009732103TC2200X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent