Healthcare Provider Details

I. General information

NPI: 1588739254
Provider Name (Legal Business Name): LISA M. KUSHNER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 ALLYN ST
BELFAST ME
04915-6720
US

IV. Provider business mailing address

8 ALLYN ST
BELFAST ME
04915-6720
US

V. Phone/Fax

Practice location:
  • Phone: 207-322-5703
  • Fax: 207-338-5297
Mailing address:
  • Phone: 207-322-5703
  • Fax: 207-338-5297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLC6880
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC6880
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: