Provider Demographics
NPI:1679451058
Name:GAUDIOSO, LISA M (MPS, MS ED)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:GAUDIOSO
Suffix:
Gender:F
Credentials:MPS, MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 TRUMAN PL
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1339
Mailing Address - Country:US
Mailing Address - Phone:631-569-0094
Mailing Address - Fax:
Practice Address - Street 1:125 TRUMAN PL
Practice Address - Street 2:
Practice Address - City:CENTERPORT
Practice Address - State:NY
Practice Address - Zip Code:11721-1339
Practice Address - Country:US
Practice Address - Phone:631-569-0094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool