Provider Demographics
NPI:1063751196
Name:DAUGHTERS, LISA J
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:DAUGHTERS
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 1:125 BAYLISS ST STE 122
Mailing Address - Street 2:
Mailing Address - City:HUTTO
Mailing Address - State:TX
Mailing Address - Zip Code:78634-5575
Mailing Address - Country:US
Mailing Address - Phone:480-287-0540
Mailing Address - Fax:
Practice Address - Street 1:4121 E VALLEY AUTO DR
Practice Address - Street 2:SUITE 122
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4631
Practice Address - Country:US
Practice Address - Phone:602-285-9696
Practice Address - Fax:602-277-5930
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC - 13752101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional