Provider Demographics
NPI:1568005163
Name:MERCADO LIRIANO, CRISTISHA GUADAPULE
Entity Type:Individual
Prefix:
First Name:CRISTISHA
Middle Name:GUADAPULE
Last Name:MERCADO LIRIANO
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 1:25 GRANITE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-3455
Mailing Address - Country:US
Mailing Address - Phone:978-710-1537
Mailing Address - Fax:
Practice Address - Street 1:25 GRANITE ST APT 1
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-3455
Practice Address - Country:US
Practice Address - Phone:978-710-1537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-26
Last Update Date:2019-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB0118648400OtherBOSTON MEDICAL CENTER (HNP)
MA100052833033OtherMASSHEALTH ID (BMC)