Provider Demographics
NPI:1871039693
Name:LISSANDRELLO, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:LISSANDRELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:NEWTONVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02460-1948
Mailing Address - Country:US
Mailing Address - Phone:617-752-7515
Mailing Address - Fax:
Practice Address - Street 1:288 WALNUT ST
Practice Address - Street 2:
Practice Address - City:NEWTONVILLE
Practice Address - State:MA
Practice Address - Zip Code:02460-1948
Practice Address - Country:US
Practice Address - Phone:617-752-7515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1217131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical