Healthcare Provider Details

I. General information

NPI: 1396601324
Provider Name (Legal Business Name): LISA DAZZELL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2026
Last Update Date: 01/03/2026
Certification Date: 01/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CLARKSON AVE
BROOKLYN NY
11203-2097
US

IV. Provider business mailing address

559 BEACH 66TH ST
ARVERNE NY
11692-1330
US

V. Phone/Fax

Practice location:
  • Phone: 718-245-1012
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number027793
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: