Provider Demographics
NPI:1053675876
Name:NORMAN, LISSETTE J (M S)
Entity type:Individual
Prefix:MS
First Name:LISSETTE
Middle Name:J
Last Name:NORMAN
Suffix:
Gender:F
Credentials:M S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22018 HORACE HARDING EXPY
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2227
Mailing Address - Country:US
Mailing Address - Phone:718-423-0056
Mailing Address - Fax:718-229-5370
Practice Address - Street 1:22018 HORACE HARDING EXPY
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11364-2227
Practice Address - Country:US
Practice Address - Phone:718-423-0056
Practice Address - Fax:718-229-5370
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator