Provider Demographics
NPI:1992258578
Name:DETENBER, LIZA (LICSW)
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:DETENBER
Suffix:
Gender:
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:867 BOYLSTON ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2774
Mailing Address - Country:US
Mailing Address - Phone:781-630-5774
Mailing Address - Fax:781-236-8615
Practice Address - Street 1:867 BOYLSTON ST FL 5
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-2774
Practice Address - Country:US
Practice Address - Phone:781-630-5774
Practice Address - Fax:781-236-8615
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 1041S0200X
MA1223971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool