Provider Demographics
NPI:1750593307
Name:LISBON, MARY VICTORIA (LICSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:VICTORIA
Last Name:LISBON
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 1:225A WALNUT AVE # 3
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1624
Mailing Address - Country:US
Mailing Address - Phone:617-626-9370
Mailing Address - Fax:
Practice Address - Street 1:180 MORTON ST
Practice Address - Street 2:ROOM 404A
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3735
Practice Address - Country:US
Practice Address - Phone:617-626-9370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10314321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical