Provider Demographics
NPI:1205055605
Name:DU BREUIL, LISA JENNETTE (LICSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JENNETTE
Last Name:DU BREUIL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BLOSSOM ST
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-3104
Mailing Address - Country:US
Mailing Address - Phone:617-724-4903
Mailing Address - Fax:617-248-0070
Practice Address - Street 1:16 BLOSSOM ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3104
Practice Address - Country:US
Practice Address - Phone:617-724-4903
Practice Address - Fax:617-248-0070
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1130681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical