Provider Demographics
NPI:1710012059
Name:MORTIMER, LISA HOLDEN (MSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:HOLDEN
Last Name:MORTIMER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 MOUNT HOOD TER
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-5822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32 FRUIT ST
Practice Address - Street 2:WAC037
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2620
Practice Address - Country:US
Practice Address - Phone:617-726-5927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1023224101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health