Provider Demographics
NPI:1346269552
Name:MOTHERWELL, LISE (PHD PSYD)
Entity Type:Individual
Prefix:DR
First Name:LISE
Middle Name:
Last Name:MOTHERWELL
Suffix:
Gender:F
Credentials:PHD PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 BEACON ST
Mailing Address - Street 2:STE 4B
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446
Mailing Address - Country:US
Mailing Address - Phone:617-738-7660
Mailing Address - Fax:617-576-2871
Practice Address - Street 1:1180 BEACON ST
Practice Address - Street 2:STE 4B
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446
Practice Address - Country:US
Practice Address - Phone:617-738-7660
Practice Address - Fax:617-576-2871
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6598103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05301Medicare ID - Type Unspecified