Provider Demographics
NPI:1558688234
Name:WAXMAN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WAXMAN
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 1:25R MARKET ST
Mailing Address - Street 2:
Mailing Address - City:IPSWICH
Mailing Address - State:MA
Mailing Address - Zip Code:01938-2212
Mailing Address - Country:US
Mailing Address - Phone:978-356-1776
Mailing Address - Fax:978-356-2822
Practice Address - Street 1:25R MARKET ST
Practice Address - Street 2:
Practice Address - City:IPSWICH
Practice Address - State:MA
Practice Address - Zip Code:01938-2212
Practice Address - Country:US
Practice Address - Phone:978-356-1776
Practice Address - Fax:978-356-2822
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1122431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical