Provider Demographics
NPI:1588960264
Name:ESTIVILL, LISA LENORA (LICSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LENORA
Last Name:ESTIVILL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 647
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05601-0647
Mailing Address - Country:US
Mailing Address - Phone:802-476-1480
Mailing Address - Fax:802-479-4095
Practice Address - Street 1:260 BECKLEY HILL RD
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-9080
Practice Address - Country:US
Practice Address - Phone:802-476-1480
Practice Address - Fax:802-479-4095
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00007311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical