Provider Demographics
NPI:1669294641
Name:POLIDORO, LISA L
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:POLIDORO
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 1:403 WAHCONAH ST APT B
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-2622
Mailing Address - Country:US
Mailing Address - Phone:413-770-7103
Mailing Address - Fax:
Practice Address - Street 1:333 EAST ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-5369
Practice Address - Country:US
Practice Address - Phone:413-629-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)