Provider Demographics
NPI:1013071786
Name:FORESTO, LISA ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:FORESTO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PINE HOLLOW RD.
Mailing Address - Street 2:# 20-4A
Mailing Address - City:EAST NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:11732
Mailing Address - Country:US
Mailing Address - Phone:516-512-1574
Mailing Address - Fax:
Practice Address - Street 1:444 COMMUNITY DR.
Practice Address - Street 2:SUITE # 306
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030
Practice Address - Country:US
Practice Address - Phone:516-512-1574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016851103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00330231Medicare ID - Type Unspecified