Provider Demographics
NPI:1124478037
Name:BOSCO, LISA KELLIE (MB BCH BAO)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:KELLIE
Last Name:BOSCO
Suffix:
Gender:F
Credentials:MB BCH BAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 THIRD ST UNIT 405
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02142-1181
Mailing Address - Country:US
Mailing Address - Phone:914-960-6900
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON PL STE 2600
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-4420
Practice Address - Country:US
Practice Address - Phone:617-420-7194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2683952084P0800X
MA2818212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry