Provider Demographics
NPI:1912426800
Name:DAVIDE, LISA MARIE (BEHAVIOR THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:DAVIDE
Suffix:
Gender:F
Credentials:BEHAVIOR THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-3550
Mailing Address - Country:US
Mailing Address - Phone:617-429-3481
Mailing Address - Fax:
Practice Address - Street 1:564 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-3550
Practice Address - Country:US
Practice Address - Phone:617-791-4137
Practice Address - Fax:617-791-4137
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty