=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982951448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA TAMI WESSAN LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2012
-----------------------------------------------------
Last Update Date | 08/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 MAIN ST
-----------------------------------------------------
City | N CHELMSFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01863-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-710-8039
-----------------------------------------------------
Fax | 978-455-0660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 MAIN ST
-----------------------------------------------------
City | N CHELMSFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01863-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-710-8039
-----------------------------------------------------
Fax | 978-455-0660
-----------------------------------------------------
=====================================================
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 | 117020
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 072240
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------