Provider Demographics
NPI:1710461264
Name:FEDERICO, LISA (LCADC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FEDERICO
Suffix:
Gender:F
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LAFAYETTE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-2120
Mailing Address - Country:US
Mailing Address - Phone:732-610-7703
Mailing Address - Fax:
Practice Address - Street 1:551 PARK AVE STE 7
Practice Address - Street 2:
Practice Address - City:SCOTCH PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07076-1768
Practice Address - Country:US
Practice Address - Phone:732-610-7703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00276800101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)