Healthcare Provider Details

I. General information

NPI: 1326269358
Provider Name (Legal Business Name): LISA LYNN PARK L.M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 02/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1938 ROUTE 6
CARMEL NY
10512-2311
US

IV. Provider business mailing address

58 DEANS BRIDGE RD
SOMERS NY
10589-2616
US

V. Phone/Fax

Practice location:
  • Phone: 845-225-5650
  • Fax:
Mailing address:
  • Phone: 845-617-3076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number074430-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: