Provider Demographics
NPI:1558563486
Name:KEYSER, LISA M (CLINICAL SOCIAL WORK)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:KEYSER
Suffix:
Gender:F
Credentials:CLINICAL SOCIAL WORK
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CLINICAL SOCIAL WORK
Mailing Address - Street 1:84 PEMBER RD
Mailing Address - Street 2:
Mailing Address - City:LEVANT
Mailing Address - State:ME
Mailing Address - Zip Code:04456-4319
Mailing Address - Country:US
Mailing Address - Phone:207-991-1848
Mailing Address - Fax:
Practice Address - Street 1:153 STATE ST
Practice Address - Street 2:UNIT 6
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1992
Practice Address - Country:US
Practice Address - Phone:207-991-1848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC97901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME282850099Medicaid