Provider Demographics
NPI:1477561488
Name:DEWITT, LISA ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA ELLEN
Middle Name:
Last Name:DEWITT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LISA ELLEN
Other - Middle Name:
Other - Last Name:ANGILLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:79 DOUBLEDAY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:CT
Mailing Address - Zip Code:06237-1400
Mailing Address - Country:US
Mailing Address - Phone:860-428-9158
Mailing Address - Fax:
Practice Address - Street 1:77 CHERRY ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-2053
Practice Address - Country:US
Practice Address - Phone:860-428-9158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CT0075771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040564Medicaid