Provider Demographics
NPI:1235666165
Name:DISLA, ALPHONSINA
Entity Type:Individual
Prefix:
First Name:ALPHONSINA
Middle Name:
Last Name:DISLA
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 1:12 HOBSON ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-4940
Mailing Address - Country:US
Mailing Address - Phone:978-902-7443
Mailing Address - Fax:
Practice Address - Street 1:12 HOBSON ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-4940
Practice Address - Country:US
Practice Address - Phone:978-902-7443
Practice Address - Fax:978-902-7443
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104100000X, 103T00000X, 101Y00000X, 101YM0800X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100026310019Medicaid