Provider Demographics
NPI:1922217959
Name:MILDEBERGER, LISA (MS, CRC, LMHC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MILDEBERGER
Suffix:
Gender:F
Credentials:MS, CRC, LMHC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MILDEBERGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CRC, LMHC
Mailing Address - Street 1:61 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5726
Mailing Address - Country:US
Mailing Address - Phone:516-804-6232
Mailing Address - Fax:516-804-6232
Practice Address - Street 1:3375 PARK AVE.
Practice Address - Street 2:SUITE 3008
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793
Practice Address - Country:US
Practice Address - Phone:718-986-3847
Practice Address - Fax:516-804-6232
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001776101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health