Provider Demographics
NPI:1730239898
Name:KAUFMAN, ILISA KIM (PSYD)
Entity type:Individual
Prefix:DR
First Name:ILISA
Middle Name:KIM
Last Name:KAUFMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2699 STIRLING RD
Mailing Address - Street 2:SUITE B-305
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-6517
Mailing Address - Country:US
Mailing Address - Phone:954-963-5363
Mailing Address - Fax:
Practice Address - Street 1:2699 STIRLING RD
Practice Address - Street 2:SUITE B-305
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-6517
Practice Address - Country:US
Practice Address - Phone:954-963-5363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 7363103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical