Provider Demographics
NPI:1003246232
Name:SAN MIGUEL, LISANDRA
Entity Type:Individual
Prefix:
First Name:LISANDRA
Middle Name:
Last Name:SAN MIGUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 ELLIOT ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105-1745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:87 ELLIOT ST APT 2A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1745
Practice Address - Country:US
Practice Address - Phone:413-214-1644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1041S0200X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool