Provider Demographics
NPI:1962010918
Name:BREA, LISAMARIE
Entity Type:Individual
Prefix:
First Name:LISAMARIE
Middle Name:
Last Name:BREA
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 1:244 FIELDSTON TER APT 5G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-3034
Mailing Address - Country:US
Mailing Address - Phone:516-320-0234
Mailing Address - Fax:
Practice Address - Street 1:1715 WEIRFIELD ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5351
Practice Address - Country:US
Practice Address - Phone:718-417-2840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14334960235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty