Provider Demographics
NPI:1104090646
Name:LOVELACE, LISA EILEEN (PSYD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:EILEEN
Last Name:LOVELACE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3539 DOUGLAS DR N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2415
Mailing Address - Country:US
Mailing Address - Phone:612-642-1355
Mailing Address - Fax:612-756-7059
Practice Address - Street 1:3539 DOUGLAS DR N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55422-2415
Practice Address - Country:US
Practice Address - Phone:612-642-1355
Practice Address - Fax:612-756-7059
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3561-57103TC0700X
NY017260103TC0700X
MNLP5379103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical