Provider Demographics
NPI:1669619573
Name:SPANO, LISA ANNA (PSYD, BCBA-D)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANNA
Last Name:SPANO
Suffix:
Gender:F
Credentials:PSYD, BCBA-D
Other - Prefix:
Other - First Name:ELISABETTA
Other - Middle Name:ANNA
Other - Last Name:PESTRICHELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 GATES PLACE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470
Mailing Address - Country:US
Mailing Address - Phone:201-694-4998
Mailing Address - Fax:
Practice Address - Street 1:35 CLYDE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-5033
Practice Address - Country:US
Practice Address - Phone:732-873-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2021-06-15
Deactivation Date:2011-07-20
Deactivation Code:
Reactivation Date:2021-06-10
Provider Licenses
StateLicense IDTaxonomies
NJ083-957103TC0700X
NJ1-05-2397103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical