Provider Demographics
NPI:1972748655
Name:ILARIA, LISA M (PSYD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:ILARIA
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 1:80 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3708
Mailing Address - Country:US
Mailing Address - Phone:503-307-0754
Mailing Address - Fax:
Practice Address - Street 1:105 GROVE ST STE 14-3
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4051
Practice Address - Country:US
Practice Address - Phone:973-983-3762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017917-1103TC0700X
NJ35SI00482800103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical