Provider Demographics
NPI:1407693583
Name:MERCADO, LISA A (MSED)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:MERCADO
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PEACHTREE CT
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-2534
Mailing Address - Country:US
Mailing Address - Phone:631-258-4198
Mailing Address - Fax:
Practice Address - Street 1:99 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-3537
Practice Address - Country:US
Practice Address - Phone:516-317-9284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist