Provider Demographics
NPI:1356965438
Name:LISCIOTTO, KATHLEEN ANN (LICSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:LISCIOTTO
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 1:5 DORAL DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01863-1814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 DORAL DR
Practice Address - Street 2:
Practice Address - City:NORTH CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01863-1814
Practice Address - Country:US
Practice Address - Phone:708-932-0831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1151931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA115193OtherLICSW