Provider Demographics
NPI:1548030745
Name:BRACAMONTE, LISA (PSY D)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:BRACAMONTE
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-7704
Mailing Address - Country:US
Mailing Address - Phone:862-926-8476
Mailing Address - Fax:
Practice Address - Street 1:14 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-7704
Practice Address - Country:US
Practice Address - Phone:862-926-8476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100697200103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty