Provider Demographics
NPI:1487107421
Name:DE LISSER, ANDREE
Entity type:Individual
Prefix:DR
First Name:ANDREE
Middle Name:
Last Name:DE LISSER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 DOGWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GOLDENS BRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10526-1115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 HOSPITAL AVE
Practice Address - Street 2:DANBURY HOSPITAL PSYCHIATRY
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:914-907-3127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004626364SP0809X
CT4626364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist