Provider Demographics
NPI:1124338611
Name:AITKEN, LISA (LCSW-R)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:AITKEN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MEMORIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764
Mailing Address - Country:US
Mailing Address - Phone:631-474-2723
Mailing Address - Fax:631-474-1734
Practice Address - Street 1:15 MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764
Practice Address - Country:US
Practice Address - Phone:631-474-2723
Practice Address - Fax:631-474-1734
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0479851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical