Provider Demographics
NPI:1003502436
Name:FORTSON, LISA GIGUERE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:GIGUERE
Last Name:FORTSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03246-3240
Mailing Address - Country:US
Mailing Address - Phone:603-491-4573
Mailing Address - Fax:
Practice Address - Street 1:166 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-3240
Practice Address - Country:US
Practice Address - Phone:603-491-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2424101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health