Provider Demographics
NPI:1831299585
Name:BOMSE, LISA E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:E
Last Name:BOMSE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 PINE RD
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4217
Mailing Address - Country:US
Mailing Address - Phone:516-921-2721
Mailing Address - Fax:
Practice Address - Street 1:9 PINE RD
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4217
Practice Address - Country:US
Practice Address - Phone:516-921-2721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011728103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01590409Medicaid
NY01590409Medicaid