Provider Demographics
NPI:1861867442
Name:LISIESKI, MARIE DOROTHEA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:DOROTHEA
Last Name:LISIESKI
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 1:2400 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606
Mailing Address - Country:US
Mailing Address - Phone:203-362-3932
Mailing Address - Fax:203-362-2463
Practice Address - Street 1:2400 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606
Practice Address - Country:US
Practice Address - Phone:203-362-3932
Practice Address - Fax:203-362-2463
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0092611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical