Provider Demographics
NPI:1336187541
Name:PELLETIER-BRANCO, LISA MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:PELLETIER-BRANCO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:BRANCO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:30 MAN MAR DR
Mailing Address - Street 2:SUITE 13
Mailing Address - City:PLAINVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02762-2249
Mailing Address - Country:US
Mailing Address - Phone:508-695-3885
Mailing Address - Fax:508-695-3889
Practice Address - Street 1:30 MAN MAR DR
Practice Address - Street 2:SUITE 13
Practice Address - City:PLAINVILLE
Practice Address - State:MA
Practice Address - Zip Code:02762-2249
Practice Address - Country:US
Practice Address - Phone:508-695-3885
Practice Address - Fax:508-695-3889
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1025607101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP20108Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #