Provider Demographics
NPI:1831110238
Name:SAMSTAG, LISA WALLNER (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:WALLNER
Last Name:SAMSTAG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 W 19TH ST
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-4216
Mailing Address - Country:US
Mailing Address - Phone:212-633-1615
Mailing Address - Fax:
Practice Address - Street 1:5 W 19TH ST
Practice Address - Street 2:9TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-4216
Practice Address - Country:US
Practice Address - Phone:212-633-1615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014004103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical