Healthcare Provider Details

I. General information

NPI: 1922916865
Provider Name (Legal Business Name): DESTA LISSANU MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT STREET WARREN SUITE 12-20
BOSTON MA
02114
US

IV. Provider business mailing address

55 FRUIT STREET WARREN SUITE 12-20
BOSTON MA
02114
US

V. Phone/Fax

Practice location:
  • Phone: 617-982-3152
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DESTA LISSANU
Title or Position: PSYCHIATRIST
Credential:
Phone: 617-982-3152