=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588739254
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA M. KUSHNER LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 04/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8 ALLYN ST
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-6720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-322-5703
-----------------------------------------------------
Fax | 207-338-5297
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 ALLYN ST
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-6720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-322-5703
-----------------------------------------------------
Fax | 207-338-5297
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LC6880
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LC6880
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------