Provider Demographics
NPI:1932156320
Name:PUPA-O'SULLIVAN, LISA M (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:PUPA-O'SULLIVAN
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 1:2164 HWY 35
Mailing Address - Street 2:BLDG B - STE 6
Mailing Address - City:SEA GIRT
Mailing Address - State:NJ
Mailing Address - Zip Code:08750
Mailing Address - Country:US
Mailing Address - Phone:732-359-7675
Mailing Address - Fax:732-359-7674
Practice Address - Street 1:2164 HWY 35
Practice Address - Street 2:BLDG B - STE 6
Practice Address - City:SEA GIRT
Practice Address - State:NJ
Practice Address - Zip Code:08750
Practice Address - Country:US
Practice Address - Phone:732-359-7675
Practice Address - Fax:732-359-7674
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00351200103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ000960064Medicare PIN
NJ1932156320Medicare PIN