Healthcare Provider Details

I. General information

NPI: 1750592291
Provider Name (Legal Business Name): LISA BONN MS ATR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA ISHWARDAS MS ATR

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2495 MAIN ST SUITE 412
BUFFALO NY
14214-2152
US

IV. Provider business mailing address

525 WASHINGTON ST
BUFFALO NY
14203-1711
US

V. Phone/Fax

Practice location:
  • Phone: 716-862-0367
  • Fax: 716-862-0368
Mailing address:
  • Phone: 716-856-4494
  • Fax: 716-842-1277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberATR 90168
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: