Provider Demographics
NPI:1164588059
Name:LIPSON, WANDA IVELISSE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:IVELISSE
Last Name:LIPSON
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 1:74 VILLAGE ST
Mailing Address - Street 2:
Mailing Address - City:MILLIS
Mailing Address - State:MA
Mailing Address - Zip Code:02054-1728
Mailing Address - Country:US
Mailing Address - Phone:508-314-2154
Mailing Address - Fax:
Practice Address - Street 1:300 HOWARD ST
Practice Address - Street 2:SMOC BEHAVIORAL HEALTH SERVICES
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-8313
Practice Address - Country:US
Practice Address - Phone:508-879-2250
Practice Address - Fax:508-481-1504
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1121351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical