Provider Demographics
NPI:1700992609
Name:ROSELLI, LISA H (MACCCA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:H
Last Name:ROSELLI
Suffix:
Gender:F
Credentials:MACCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1655
Mailing Address - Country:US
Mailing Address - Phone:516-617-1599
Mailing Address - Fax:
Practice Address - Street 1:450 WILLIAM FLOYD PKWY STE B
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-3480
Practice Address - Country:US
Practice Address - Phone:516-617-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0014931231H00000X, 231HA2400X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter