MEDICARE: LISA GERSONY

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	103TC0700X	Clinical Psychologist	PY8817	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1538356787	OTHER	FL	MEDICARE

General Provider Information

NPI Number	:	1538356787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA GERSONY

Provider Business Mailing Address
First Line	:	1801 SW CALIFORNIA BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-1164
Country	:	US
Telephone Number	:	860-808-6693
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 SW CALIFORNIA BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-1164
Country	:	US
Telephone Number	:	860-808-6693
Fax Number	:

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

Provider Enumeration Date	:	10/02/2007
Last Update Date	:	10/17/2014

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