Healthcare Provider Details

I. General information

NPI: 1417416165
Provider Name (Legal Business Name): YISROEL MORDECHAI LYSS LMFT, LCMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 BEDFORD AVE STE 113
BALTIMORE MD
21208-3737
US

IV. Provider business mailing address

3607 BANCROFT RD
BALTIMORE MD
21215-3229
US

V. Phone/Fax

Practice location:
  • Phone: 203-706-8747
  • Fax:
Mailing address:
  • Phone: 443-386-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLCM987
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number002588
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: