Individual
DESTA LISSANU
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
55 FRUIT ST, BOSTON, MA 02114-2621
(617) 726-9550
Mailing address
58 WELD HILL ST, BOSTON, MA 02130-4187
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
290272
MA
Other
Enumeration date
03/19/2019
Last updated
04/16/2023
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