Provider Demographics
NPI:1780720243
Name:POLENBERG, LISA (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:POLENBERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 5TH AVE RM 808
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6647
Mailing Address - Country:US
Mailing Address - Phone:212-337-1441
Mailing Address - Fax:
Practice Address - Street 1:303 5TH AVE RM 808
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6647
Practice Address - Country:US
Practice Address - Phone:212-337-1441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO44729-11041C0700X
NYRO4772911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN14741Medicare ID - Type Unspecified