Provider Demographics
NPI:1194301606
Name:FANT, LISHA (LCDC)
Entity type:Individual
Prefix:
First Name:LISHA
Middle Name:
Last Name:FANT
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 HUNTLEIGH DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-1405
Mailing Address - Country:US
Mailing Address - Phone:325-716-6333
Mailing Address - Fax:
Practice Address - Street 1:3941 HOLCOMB BRIDGE RD STE 100
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-2292
Practice Address - Country:US
Practice Address - Phone:855-850-0274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11296101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty