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NPI Code Detail

MEDICARE: MRS. LISA MARIE DAVIDE BEHAVIOR THERAPIST

MEDICARE: MRS. LISA MARIE DAVIDE BEHAVIOR THERAPIST
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1912426800
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. LISA MARIE DAVIDE BEHAVIOR THERAPIST
Provider Business Mailing Address
First Line : 564 PLEASANT ST
Second Line :
City : MALDEN
State : MA
Zip : 02148-3550
Country : US
Telephone Number : 617-429-3481
Fax Number :
Provider Business Practice Location Address
First Line : 564 PLEASANT ST
Second Line :
City : MALDEN
State : MA
Zip : 02148-3550
Country : US
Telephone Number : 617-791-4137
Fax Number : 617-791-4137
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/12/2017
Last Update Date : 06/16/2018

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