Provider Demographics
NPI:1992473854
Name:DATRI, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DATRI
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 1:20 STARGAZER DR
Mailing Address - Street 2:
Mailing Address - City:EASTPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11941-1629
Mailing Address - Country:US
Mailing Address - Phone:631-624-7740
Mailing Address - Fax:
Practice Address - Street 1:AJ BEHAVORIAL
Practice Address - Street 2:2631 MERRICK ROAD SUITE 302 BELLMORE, NY 11710
Practice Address - City:BELLMORE,
Practice Address - State:NY
Practice Address - Zip Code:11710
Practice Address - Country:US
Practice Address - Phone:516-590-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY103K00000XOtherAJ BEHAVIORAL