Provider Demographics
NPI:1881289890
Name:CARRUTHERS, MIRTA LISSO
Entity type:Individual
Prefix:
First Name:MIRTA
Middle Name:LISSO
Last Name:CARRUTHERS
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 1:3603 EAST WEST HWY.
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815
Mailing Address - Country:US
Mailing Address - Phone:301-986-0787
Mailing Address - Fax:
Practice Address - Street 1:6TH AND BRYANT STREETS
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20059-0001
Practice Address - Country:US
Practice Address - Phone:202-806-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC14409101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor