Provider Demographics
NPI:1124002571
Name:WALLACE, LISA M (MA, LPC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 273338
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80527-3338
Mailing Address - Country:US
Mailing Address - Phone:970-817-4049
Mailing Address - Fax:877-833-4460
Practice Address - Street 1:4103 E BOARDWALK DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5930
Practice Address - Country:US
Practice Address - Phone:970-817-4049
Practice Address - Fax:877-833-4460
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY906101YM0800X
CO5913101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY312410OtherBS OF WY