Provider Demographics
NPI:1629352968
Name:MORISHANTI, LISA M (LICSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MORISHANTI
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:MORIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4001
Practice Address - Country:US
Practice Address - Phone:617-414-4931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1164111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
002540601Medicare PIN