Provider Demographics
NPI:1770763237
Name:YOUNG, LISSA (PHD)
Entity type:Individual
Prefix:DR
First Name:LISSA
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 TURNPIKE ST STE 12C
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-2847
Mailing Address - Country:US
Mailing Address - Phone:781-462-1845
Mailing Address - Fax:
Practice Address - Street 1:1017 TURNPIKE ST STE 12C
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2847
Practice Address - Country:US
Practice Address - Phone:781-462-1845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9714103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service