Provider Demographics
NPI:1841440062
Name:LISS, JONATHAN MARTIN (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MARTIN
Last Name:LISS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 BROADWAY
Mailing Address - Street 2:SUITE 721
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-7903
Mailing Address - Country:US
Mailing Address - Phone:917-647-4270
Mailing Address - Fax:
Practice Address - Street 1:1133 BROADWAY
Practice Address - Street 2:SUITE 721
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7903
Practice Address - Country:US
Practice Address - Phone:917-647-4270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017752103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical