Basic Information
| Provider Information | |||||||||
| NPI: | 1376594036 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LISA C. MCELROY, PHD, PSYCHOLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 TAUGHANNOCK BLVD | ||||||||
| Address2: | PO BOX 366 | ||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072773257 | ||||||||
| FaxNumber: | 6072774056 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 EVERGREEN STREET | ||||||||
| Address2: | |||||||||
| City: | DRYDEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072731300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCELROY | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6072731300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 02104236 | 05 | NY | MEDICAID |