Provider Demographics
NPI:1932194917
Name:DE LISIO, MICHELLE (LICSW, LADC)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:DE LISIO
Suffix:
Gender:F
Credentials:LICSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01301-2512
Mailing Address - Country:US
Mailing Address - Phone:413-772-8826
Mailing Address - Fax:413-774-5946
Practice Address - Street 1:25 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301-2512
Practice Address - Country:US
Practice Address - Phone:413-772-8826
Practice Address - Fax:413-774-5946
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA314101YA0400X
MA10195131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07257OtherBLUE CROSS/BLUE SHIELD
MA156061OtherMANAGED HEALTH NETWORK
MA101951OtherTUFTS HEALTH PLAN
MA156061OtherMANAGED HEALTH NETWORK