Basic Information
| Provider Information | |||||||||
| NPI: | 1770817538 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASTOS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUSSELL | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15 TOWNE ST | ||||||||
| Address2: | |||||||||
| City: | NORTH ATTLEBORO | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027604008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025683581 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20 EASTBOOK RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | DEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813299365 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2009 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 685661 | 01 | MA | TUFTS | OTHER | 110026265E | 05 | MA | MEDICAID |