Provider Demographics
NPI:1750592291
Name:BONN, LISA (MS ATR)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BONN
Suffix:
Gender:F
Credentials:MS ATR
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:ISHWARDAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS ATR
Mailing Address - Street 1:525 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1711
Mailing Address - Country:US
Mailing Address - Phone:716-856-4494
Mailing Address - Fax:716-842-1277
Practice Address - Street 1:2495 MAIN ST
Practice Address - Street 2:SUITE 412
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2152
Practice Address - Country:US
Practice Address - Phone:716-862-0367
Practice Address - Fax:716-862-0368
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYATR 90168102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst