Provider Demographics
NPI:1821151895
Name:BURCH, LISA P (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:P
Last Name:BURCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MIRIAM
Other - Last Name:PASSALACQUA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19 PINNEY ST
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-3812
Mailing Address - Country:US
Mailing Address - Phone:860-871-9295
Mailing Address - Fax:860-871-9271
Practice Address - Street 1:19 PINNEY ST
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-3812
Practice Address - Country:US
Practice Address - Phone:860-871-9295
Practice Address - Fax:860-871-9271
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0016281041C0700X
MA1052561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT140001628CT03OtherANTHEM BC PIN
CT001628OtherLICENSE
MA105256OtherLICENSE
11241472OtherCAQH PIN
11241472OtherCAQH PIN