Basic Information
| Provider Information | |||||||||
| NPI: | 1750592291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS ATR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ISHWARDAS | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MS ATR | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 525 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168564494 | ||||||||
| FaxNumber: | 7168421277 | ||||||||
| Practice Location | |||||||||
| Address1: | 2495 MAIN ST | ||||||||
| Address2: | SUITE 412 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142142152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168620367 | ||||||||
| FaxNumber: | 7168620368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 102L00000X | ATR 90168 | NY | Y | Behavioral Health & Social Service Providers | Psychoanalyst |
No ID Information.