Provider Demographics
NPI:1366759219
Name:JOHN, LISA MEDEIROS
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MEDEIROS
Last Name:JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904-2540
Mailing Address - Country:US
Mailing Address - Phone:781-599-3109
Mailing Address - Fax:781-599-3162
Practice Address - Street 1:30 BOSTON ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-2540
Practice Address - Country:US
Practice Address - Phone:781-599-3109
Practice Address - Fax:781-599-3162
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health