Healthcare Provider Details

I. General information

NPI: 1417455676
Provider Name (Legal Business Name): LISA MARIE COGSWELL MS SP. ED., SBL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2690 WILDDALE RD
BALDWIN NY
11510-4127
US

IV. Provider business mailing address

2690 WILDDALE RD
BALDWIN NY
11510-4127
US

V. Phone/Fax

Practice location:
  • Phone: 347-729-8909
  • Fax: 646-868-1230
Mailing address:
  • Phone: 347-729-8909
  • Fax: 646-868-1230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number1730721
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1730721
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: