Provider Demographics
NPI:1760493613
Name:BAILYN, LISA (PHD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BAILYN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 DUNDEE PARK
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3723
Mailing Address - Country:US
Mailing Address - Phone:978-475-3590
Mailing Address - Fax:
Practice Address - Street 1:3 DUNDEE PARK
Practice Address - Street 2:SUITE 203
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3723
Practice Address - Country:US
Practice Address - Phone:978-475-3590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6685103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist