Basic Information
| Provider Information | |||||||||
| NPI: | 1164588059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIPSON | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | IVELISSE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 74 VILLAGE ST | ||||||||
| Address2: | |||||||||
| City: | MILLIS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020541728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083142154 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 HOWARD ST | ||||||||
| Address2: | SMOC BEHAVIORAL HEALTH SERVICES | ||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017028313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088792250 | ||||||||
| FaxNumber: | 5084811504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 112135 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.