Provider Demographics
NPI:1700100724
Name:JUNG, LISA TYMESON (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:TYMESON
Last Name:JUNG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-1947
Mailing Address - Country:US
Mailing Address - Phone:207-745-9399
Mailing Address - Fax:
Practice Address - Street 1:75 STATE ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1947
Practice Address - Country:US
Practice Address - Phone:207-745-9399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC7628101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)