MEDICARE: DR. LISA K PASS PH. D.

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	103TC2200X	Clinical Child & Adolescent Psychologist	009732	NY
2	103TS0200X	School Psychologist	009732	NY

General Provider Information

NPI Number	:	1659494953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA K PASS PH. D.

Provider Business Mailing Address
First Line	:	2 E END AVE
Second Line	:	APT 2A
City	:	NEW YORK
State	:	NY
Zip	:	10075-1192
Country	:	US
Telephone Number	:	917-974-9150
Fax Number	:

Provider Business Practice Location Address
First Line	:	240 W 102ND ST
Second Line	:	SUITE 15
City	:	NEW YORK
State	:	NY
Zip	:	10025-4900
Country	:	US
Telephone Number	:	917-974-9150
Fax Number	:

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

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	05/23/2013

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