Provider Demographics
NPI:1124304571
Name:DIMITRI, LISA A (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:DIMITRI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 BILTMORE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1157
Mailing Address - Country:US
Mailing Address - Phone:631-678-7170
Mailing Address - Fax:
Practice Address - Street 1:755 MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1801
Practice Address - Country:US
Practice Address - Phone:631-678-7170
Practice Address - Fax:631-224-8940
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR074292-1101YM0800X
NY074292-1101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health