Provider Demographics
NPI:1790040558
Name:EGAN, LISA M (MS ED)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:EGAN
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 BROWN BLVD
Mailing Address - Street 2:
Mailing Address - City:WHEATLEY HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11798-1516
Mailing Address - Country:US
Mailing Address - Phone:631-487-3871
Mailing Address - Fax:
Practice Address - Street 1:65 BROWN BLVD
Practice Address - Street 2:
Practice Address - City:WHEATLEY HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11798-1516
Practice Address - Country:US
Practice Address - Phone:631-487-3871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY675170769174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist