Provider Demographics
NPI:1871311480
Name:PARADISSIS, MARY (LAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PARADISSIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 BROWNING TER
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-4223
Mailing Address - Country:US
Mailing Address - Phone:848-391-9081
Mailing Address - Fax:
Practice Address - Street 1:721 N BEERS ST STE 2E
Practice Address - Street 2:
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1500
Practice Address - Country:US
Practice Address - Phone:732-888-4910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00173800171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist