Provider Demographics
NPI:1881770196
Name:BROTHWELL, LISA MANNING (PHD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MANNING
Last Name:BROTHWELL
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 1:552 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-2915
Mailing Address - Country:US
Mailing Address - Phone:716-667-2105
Mailing Address - Fax:716-655-6077
Practice Address - Street 1:552 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-2915
Practice Address - Country:US
Practice Address - Phone:716-667-2105
Practice Address - Fax:716-655-6077
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011047-1103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIAO452Medicare ID - Type Unspecified