Provider Demographics
NPI:1982199816
Name:COSGROVE, LISA A (PHD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:COSGROVE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4278
Mailing Address - Country:US
Mailing Address - Phone:617-287-7748
Mailing Address - Fax:
Practice Address - Street 1:415 BROADWAY
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4278
Practice Address - Country:US
Practice Address - Phone:857-998-8729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-23
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6171-PY-PR103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist