Provider Demographics
NPI:1750628533
Name:LIN, LISA (MSLAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LIN
Suffix:
Gender:F
Credentials:MSLAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BOND ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2016
Mailing Address - Country:US
Mailing Address - Phone:516-829-8088
Mailing Address - Fax:
Practice Address - Street 1:15 BOND ST
Practice Address - Street 2:SUITE 112
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2016
Practice Address - Country:US
Practice Address - Phone:516-829-8088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-13
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003307171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist