Provider Demographics
NPI:1780191270
Name:FENNELLY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FENNELLY
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 1:15 W PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-2161
Mailing Address - Country:US
Mailing Address - Phone:732-254-0600
Mailing Address - Fax:
Practice Address - Street 1:15 W PROSPECT ST
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-2161
Practice Address - Country:US
Practice Address - Phone:732-254-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-05
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37FI00196000106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist