Basic Information
Provider Information | |||||||||
NPI: | 1649533852 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLATT | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BLATT | ||||||||
OtherFirstName: | CHAYA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 40 1ST AVE | ||||||||
Address2: | APT. 6E | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100097630 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9175093266 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 535 8TH AVE | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100184305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2127879700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2012 | ||||||||
LastUpdateDate: | 08/29/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | Y |   | Other Service Providers | Specialist |   |
No ID Information.