Provider Demographics
NPI:1538710744
Name:RA, LISA (MA, LAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RA
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HARVEY ST
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-1132
Mailing Address - Country:US
Mailing Address - Phone:201-673-0579
Mailing Address - Fax:
Practice Address - Street 1:22-08 ROUTE 208 STE 16
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2609
Practice Address - Country:US
Practice Address - Phone:201-956-6363
Practice Address - Fax:201-956-6026
Is Sole Proprietor?:No
Enumeration Date:2019-09-28
Last Update Date:2019-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00463800101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional