Provider Demographics
NPI:1659756856
Name:DEGE, LIA
Entity Type:Individual
Prefix:MISS
First Name:LIA
Middle Name:
Last Name:DEGE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LIA
Other - Middle Name:SEBSIBE
Other - Last Name:DEGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:21 WALDEN SQUARE RD
Mailing Address - Street 2:APT# 668
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-3443
Mailing Address - Country:US
Mailing Address - Phone:617-466-6649
Mailing Address - Fax:
Practice Address - Street 1:415 NEPONEST AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122
Practice Address - Country:US
Practice Address - Phone:617-949-6115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical