Provider Demographics
NPI:1669685053
Name:SIROTI, LISA DALE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:DALE
Last Name:SIROTI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BEECHWOOD TER
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-3001
Mailing Address - Country:US
Mailing Address - Phone:732-770-0428
Mailing Address - Fax:732-583-2412
Practice Address - Street 1:1 BEECHWOOD TER
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-3001
Practice Address - Country:US
Practice Address - Phone:732-770-0428
Practice Address - Fax:732-583-2412
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC052628001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0091723Medicaid