Basic Information
| Provider Information | |||||||||
| NPI: | 1427569508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RADIL | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 ROSEWOOD TER | ||||||||
| Address2: | |||||||||
| City: | LINDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070364923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9083585037 | ||||||||
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| Practice Location | |||||||||
| Address1: | 95 FARLEY AVE | ||||||||
| Address2: | |||||||||
| City: | FANWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070231004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274925369 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2017 | ||||||||
| LastUpdateDate: | 09/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | 1-19-36879 | NJ | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.