Provider Demographics
NPI:1457697856
Name:PRUDENTI, LISA A (LMHC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:PRUDENTI
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 916
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-0916
Mailing Address - Country:US
Mailing Address - Phone:631-921-9241
Mailing Address - Fax:
Practice Address - Street 1:30 FLOYDS RUN
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-2212
Practice Address - Country:US
Practice Address - Phone:631-567-7760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005340-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health