Provider Demographics
NPI:1770875403
Name:DEDOMENICO, LISA A
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:DEDOMENICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 E SUNNYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:10533-1004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:65 PARROTT RD
Practice Address - Street 2:
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-1025
Practice Address - Country:US
Practice Address - Phone:845-627-4829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-13
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017810103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist