Provider Demographics
NPI:1063526564
Name:FRAIDIN, LISA (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FRAIDIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BLOCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:84 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6021
Mailing Address - Country:US
Mailing Address - Phone:203-207-3233
Mailing Address - Fax:203-207-3236
Practice Address - Street 1:84 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6021
Practice Address - Country:US
Practice Address - Phone:203-207-3233
Practice Address - Fax:203-207-3236
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002638103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03323Medicare ID - Type UnspecifiedGROUP