Provider Demographics
NPI:1740431667
Name:SUPINO, LISA MICHELLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MICHELLE
Last Name:SUPINO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 B OLD MOUNT KISCO RD
Mailing Address - Street 2:
Mailing Address - City:ARMONK
Mailing Address - State:NY
Mailing Address - Zip Code:10504
Mailing Address - Country:US
Mailing Address - Phone:858-254-4302
Mailing Address - Fax:
Practice Address - Street 1:6 THORNDAL CIRCLE
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:CT
Practice Address - Zip Code:06820
Practice Address - Country:US
Practice Address - Phone:858-254-4302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017490-1103TC0700X
CT002888103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical