Healthcare Provider Details

I. General information

NPI: 1598095010
Provider Name (Legal Business Name): FELISE LUISE LLANO LISCW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 CITY HALL MALL HARVARD VANGUARD MEDICAL ASSOCIATES
MEDFORD MA
02155-4754
US

IV. Provider business mailing address

26 CITY HALL MALL HARVARD VANGUARD MEDICAL ASSOCIATES
MEDFORD MA
02155-4754
US

V. Phone/Fax

Practice location:
  • Phone: 781-306-5463
  • Fax: 781-306-5015
Mailing address:
  • Phone: 781-306-5463
  • Fax: 781-306-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106639
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: