Provider Demographics
NPI:1912113564
Name:DUTRA, LISSA MARIE (PHD)
Entity Type:Individual
Prefix:
First Name:LISSA
Middle Name:MARIE
Last Name:DUTRA
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 1:10 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-2322
Mailing Address - Country:US
Mailing Address - Phone:617-230-3002
Mailing Address - Fax:617-849-5863
Practice Address - Street 1:2 BREWER ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5710
Practice Address - Country:US
Practice Address - Phone:617-230-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MATBA103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical