Provider Demographics
NPI:1770817538
Name:BASTOS, LISA E (LMHC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:E
Last Name:BASTOS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 TOWNE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-4008
Mailing Address - Country:US
Mailing Address - Phone:602-568-3581
Mailing Address - Fax:
Practice Address - Street 1:20 EASTBOOK RD
Practice Address - Street 2:SUITE 103
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026
Practice Address - Country:US
Practice Address - Phone:781-329-9365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA685661OtherTUFTS
MA110026265EMedicaid