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General NPI Number Information
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NPI Number | 1922217959
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Entity Type | Individual
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Provider Name | LISA MILDEBERGER MS, CRC, LMHC
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Gender | Female
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 05/02/2014
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Provider Practice Location Address
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Address Line | 3375 PARK AVE. SUITE 3008
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City | WANTAGH
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State | NY
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Zip | 11793
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Country | US
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Telephone | 718-986-3847
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Fax | 516-804-6232
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Provider Business Mailing Address
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Address Line | 61 CEDAR ST
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City | MASSAPEQUA
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State | NY
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Zip | 11758-5726
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Country | US
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Telephone | 516-804-6232
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Fax | 516-804-6232
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 001776
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License Number State | NY
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