Provider Demographics
NPI:1326106543
Name:TIESZEN, LISA A (MA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:TIESZEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 600062
Mailing Address - Street 2:
Mailing Address - City:NEWTONVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02460-0001
Mailing Address - Country:US
Mailing Address - Phone:617-964-3525
Mailing Address - Fax:617-964-3525
Practice Address - Street 1:233 HARVARD STREET
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446
Practice Address - Country:US
Practice Address - Phone:617-964-3525
Practice Address - Fax:617-964-3525
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1057141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP04180OtherBLUE CROSS & BLUE SHIELD
MA550010006136OtherPACIFICARE BEHAVIORAL HEA