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General NPI Number Information
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NPI Number | 1114453305
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Entity Type | Individual
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Provider Name | LISA SPRAGUE LCSW
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Gender | Female
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Dates
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Enumeration Date | 05/07/2017
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Last Update Date | 01/12/2025
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Provider Practice Location Address
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Address Line | 793 SYCAMORE AVE
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City | BOHEMIA
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State | NY
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Zip | 11716-3514
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Country | US
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Telephone | 631-291-5101
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 214
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City | GREAT RIVER
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State | NY
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Zip | 11739-0214
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Country | US
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Telephone | 631-316-3828
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 88407
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License Number State | NY
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