Provider Demographics
NPI:1871938258
Name:MOSES, LISA (PSYD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:MOSES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 MAMARONECK AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-1662
Mailing Address - Country:US
Mailing Address - Phone:347-645-2445
Mailing Address - Fax:
Practice Address - Street 1:933 MAMARONECK AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-1662
Practice Address - Country:US
Practice Address - Phone:347-645-2445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021136103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical