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General NPI Number Information
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NPI Number | 1922916865
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Entity Type | Organization
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Legal Business Name | DESTA LISSANU MD, LLC
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Dates
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Enumeration Date | 08/31/2026
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Last Update Date | 08/31/2026
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Provider Practice Location Address
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Address Line | 55 FRUIT STREET WARREN SUITE 12-20
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City | BOSTON
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State | MA
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Zip | 02114
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Country | US
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Telephone | 617-982-3152
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Fax |
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Provider Business Mailing Address
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Address Line | 55 FRUIT STREET WARREN SUITE 12-20
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City | BOSTON
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State | MA
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Zip | 02114
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PSYCHIATRIST
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Name | DESTA LISSANU
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Credential |
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Telephone | 617-982-3152
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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