Healthcare Provider Details

I. General information

NPI: 1487257523
Provider Name (Legal Business Name): LISANDRA DJU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 HOPE ST
PROVIDENCE RI
02906-2001
US

IV. Provider business mailing address

63 BRISTOL AVE
PAWTUCKET RI
02861-2117
US

V. Phone/Fax

Practice location:
  • Phone: 401-331-1350
  • Fax:
Mailing address:
  • Phone: 401-572-8052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT00218
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: