Healthcare Provider Details

I. General information

NPI: 1174620876
Provider Name (Legal Business Name): LISA SANTOSTEFANO M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 VICTORY RD
QUINCY MA
02171-3139
US

IV. Provider business mailing address

167 SAFFORD ST
QUINCY MA
02170-1524
US

V. Phone/Fax

Practice location:
  • Phone: 617-774-1040
  • Fax: 617-847-0915
Mailing address:
  • Phone: 617-479-8034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: