Provider Demographics
NPI:1043645070
Name:AZZOLI, LISA ANN (MFA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:AZZOLI
Suffix:
Gender:F
Credentials:MFA
Other - Prefix:MR
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:BIENVENU-AZZOLI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFA
Mailing Address - Street 1:12 WESTFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-2563
Mailing Address - Country:US
Mailing Address - Phone:617-795-0484
Mailing Address - Fax:
Practice Address - Street 1:789 CLAPBOARDTREE ST
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:MA
Practice Address - Zip Code:02090-1717
Practice Address - Country:US
Practice Address - Phone:781-461-5950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS36940243101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health