Provider Demographics
NPI:1720578644
Name:CORLETO, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CORLETO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14732 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-4082
Mailing Address - Country:US
Mailing Address - Phone:718-786-5000
Mailing Address - Fax:
Practice Address - Street 1:14732 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-4082
Practice Address - Country:US
Practice Address - Phone:718-786-5000
Practice Address - Fax:718-291-4214
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0916451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty