Provider Demographics
NPI:1669593786
Name:DIRECTOR, LISA (PHD)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:DIRECTOR
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 1:124 W 79TH ST
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-6470
Mailing Address - Country:US
Mailing Address - Phone:212-362-0705
Mailing Address - Fax:
Practice Address - Street 1:124 W 79TH ST
Practice Address - Street 2:SUITE 1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6470
Practice Address - Country:US
Practice Address - Phone:212-362-0705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2012-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011503103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical