Provider Demographics
NPI:1417770645
Name:BAGDAN, LIZA ELLEN (PEER COUNSELOR)
Entity type:Individual
Prefix:MS
First Name:LIZA
Middle Name:ELLEN
Last Name:BAGDAN
Suffix:
Gender:F
Credentials:PEER COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6850 ALDERTON ST
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-5321
Mailing Address - Country:US
Mailing Address - Phone:516-698-8431
Mailing Address - Fax:
Practice Address - Street 1:497 ROCKAWAY AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1909
Practice Address - Country:US
Practice Address - Phone:718-845-2621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYCPS-P-4584175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY907214704OtherLICENSE