Provider Demographics
NPI:1790503555
Name:LOLANDESACOSTA, LISSET
Entity type:Individual
Prefix:
First Name:LISSET
Middle Name:
Last Name:LOLANDESACOSTA
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 1:32 INDIAN HILL ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-2847
Mailing Address - Country:US
Mailing Address - Phone:860-900-9066
Mailing Address - Fax:
Practice Address - Street 1:32 INDIAN HILL ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-2847
Practice Address - Country:US
Practice Address - Phone:860-900-9066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst