Provider Demographics
NPI:1922265222
Name:LISIESKI, LORI PEPPER
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:PEPPER
Last Name:LISIESKI
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 1:8 NORTHAMPTON RD
Mailing Address - Street 2:CHILDREN'S MH CLINIC
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-3224
Mailing Address - Country:US
Mailing Address - Phone:518-843-7520
Mailing Address - Fax:518-843-7537
Practice Address - Street 1:234 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-1935
Practice Address - Country:US
Practice Address - Phone:518-775-5723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR039923-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical