Provider Demographics
NPI:1679949101
Name:LIRA DE LA ROSA, ERNESTO NOAM
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:NOAM
Last Name:LIRA DE LA ROSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 TAAFFE PL
Mailing Address - Street 2:APT 408
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-4373
Mailing Address - Country:US
Mailing Address - Phone:414-507-6248
Mailing Address - Fax:
Practice Address - Street 1:262 TAAFFE PL
Practice Address - Street 2:APT 408
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-4373
Practice Address - Country:US
Practice Address - Phone:414-507-6248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program