MEDICARE: MS. LISA MARIE WISEL MS,ADTR-LCAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	000708	NY

General Provider Information

NPI Number	:	1265643860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA MARIE WISEL MS,ADTR-LCAT

Provider Business Mailing Address
First Line	:	410 E BROADWAY
Second Line	:	NUMBER 2T
City	:	LONG BEACH
State	:	NY
Zip	:	11561-4446
Country	:	US
Telephone Number	:	516-431-8788
Fax Number	:	516-431-8788

Provider Business Practice Location Address
First Line	:	410 E BROADWAY
Second Line	:	NUMBER 2T
City	:	LONG BEACH
State	:	NY
Zip	:	11561-4446
Country	:	US
Telephone Number	:	516-431-8788
Fax Number	:	516-431-8788

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	07/08/2007

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