Provider Demographics
NPI:1083725766
Name:MARTIN, LISE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LISE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 WASHINGTON ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-3518
Mailing Address - Country:US
Mailing Address - Phone:978-741-7890
Mailing Address - Fax:978-741-7890
Practice Address - Street 1:70 WASHINGTON ST
Practice Address - Street 2:SUITE 320
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-3518
Practice Address - Country:US
Practice Address - Phone:978-741-7890
Practice Address - Fax:978-741-7890
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6582103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA762170OtherMEDEX BC
MA1083725766OtherY62170