Provider Demographics
NPI:1760127385
Name:BLACK, LISA (CASAC-2)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:CASAC-2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 NORTHWIND RD
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-1730
Mailing Address - Country:US
Mailing Address - Phone:914-707-2544
Mailing Address - Fax:
Practice Address - Street 1:20 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601
Practice Address - Country:US
Practice Address - Phone:914-683-8050
Practice Address - Fax:914-683-8054
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32421101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)