Provider Demographics
NPI:1710302542
Name:FARGNOLI, LISA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:FARGNOLI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 PHOENIX AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-1418
Mailing Address - Country:US
Mailing Address - Phone:203-756-8021
Mailing Address - Fax:203-756-8021
Practice Address - Street 1:9-14 FOREST GLEN CIR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-6656
Practice Address - Country:US
Practice Address - Phone:631-885-5102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT84821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical