Doctor Name: | DR. MICHAEL BRUCE LISTER |
NPI Number: | 1215203914 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | PSY.D. |
License Number: | 0810004531 |
Business Practice Address: | 423 E Main St #2 Endicott, NY - 137606940 |
Business Phone Number: | 6077541101 |
Business Fax Number: | 6077541107 |
Mailing Address: | 423 E Main St, #3 ENDICOTT |
State: | NY |
Postal Code: | 137606940 |
Phone Number: | 6077541101 |
Fax Number: | 6077541107 |
NPI Enumeration Date: | 03/27/2012 |
NPI Last Update Date: | 08/12/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | 0810004531 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | VA |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |