Provider Demographics
NPI:1689955866
Name:LISAK, JUSTIN B
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:B
Last Name:LISAK
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 1:3105 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-7042
Mailing Address - Country:US
Mailing Address - Phone:954-328-2802
Mailing Address - Fax:
Practice Address - Street 1:3105 HARRISON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-7042
Practice Address - Country:US
Practice Address - Phone:954-328-2802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst