Provider Demographics
NPI:1073289054
Name:MINICHIELLO, LISSAANN WODIN
Entity Type:Individual
Prefix:
First Name:LISSAANN
Middle Name:WODIN
Last Name:MINICHIELLO
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 1:6 BOWDOIN DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-1235
Mailing Address - Country:US
Mailing Address - Phone:978-399-8242
Mailing Address - Fax:
Practice Address - Street 1:651 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-2919
Practice Address - Country:US
Practice Address - Phone:508-620-1442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker