Provider Demographics
NPI:1912181132
Name:MUSTILLO, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MUSTILLO
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 1:180 MONTGOMERY ST NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1440
Mailing Address - Country:US
Mailing Address - Phone:917-992-7896
Mailing Address - Fax:
Practice Address - Street 1:180 MONTGOMERY ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1440
Practice Address - Country:US
Practice Address - Phone:917-992-7896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY08295521041C0700X
GACSW0064811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical