Provider Demographics
NPI:1386128734
Name:DEZSO, LISA (LCSW, LADC, CCS)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:DEZSO
Suffix:
Gender:F
Credentials:LCSW, LADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-4823
Mailing Address - Country:US
Mailing Address - Phone:207-474-8368
Mailing Address - Fax:207-872-0639
Practice Address - Street 1:5 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-4823
Practice Address - Country:US
Practice Address - Phone:207-474-8368
Practice Address - Fax:074-747-7794
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC7112101YA0400X
MELC193191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)