Provider Demographics
NPI:1205138732
Name:CROSS, LISA WARREN (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:WARREN
Last Name:CROSS
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 1:100 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-1283
Mailing Address - Country:US
Mailing Address - Phone:203-865-7445
Mailing Address - Fax:203-222-1596
Practice Address - Street 1:100 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-1283
Practice Address - Country:US
Practice Address - Phone:203-865-7445
Practice Address - Fax:203-222-1596
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-05
Last Update Date:2010-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001986103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
600612565OtherPRACTITIONER ID NUMBER