Provider Demographics
NPI:1912241068
Name:PERSAD, LISA (PHD, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PERSAD
Suffix:
Gender:F
Credentials:PHD, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BEACH 26TH ST APT 1105
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2239
Mailing Address - Country:US
Mailing Address - Phone:347-809-1764
Mailing Address - Fax:
Practice Address - Street 1:120 BEACH 26TH ST APT 1105
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2239
Practice Address - Country:US
Practice Address - Phone:347-809-1764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF402222363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health