Provider Demographics
NPI:1669597761
Name:ZOLLMAN, LISA ROBIN (MA CCC A)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ROBIN
Last Name:ZOLLMAN
Suffix:
Gender:F
Credentials:MA CCC A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 SAINT NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-2296
Mailing Address - Country:US
Mailing Address - Phone:718-416-3277
Mailing Address - Fax:718-456-1491
Practice Address - Street 1:311 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-2296
Practice Address - Country:US
Practice Address - Phone:718-416-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0012261231H00000X
NY001226-1332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01987475Medicaid
NY01987475Medicaid