Provider Demographics
NPI:1285141523
Name:PHELPS, LISA RENE'
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENE'
Last Name:PHELPS
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 1:1303 STATION CIR
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-4585
Mailing Address - Country:US
Mailing Address - Phone:339-225-1648
Mailing Address - Fax:
Practice Address - Street 1:1153 CENTRE ST STE 5J
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-983-7383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1195361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical