Provider Demographics
NPI:1245380377
Name:WOLFE, LISA H
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:H
Last Name:WOLFE
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 1:173 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4005
Mailing Address - Country:US
Mailing Address - Phone:617-924-0303
Mailing Address - Fax:
Practice Address - Street 1:173 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4005
Practice Address - Country:US
Practice Address - Phone:617-924-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6250103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA766312OtherTUFTS HEALTH PLAN
MA0521736Medicaid
MA1171331OtherCCN FIRST HEALTH
MA0521736Medicaid