Basic Information
| Provider Information | |||||||||
| NPI: | 1639392343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LISENO | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 A NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | SOUTH DEERFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4136654019 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2155 MAIN STREET | ||||||||
| Address2: | GANDARA CENTER | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137360395 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.