Provider Demographics
NPI:1285168260
Name:KOEHL, LISA (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KOEHL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:740 S LIMESTONE
Mailing Address - Street 2:KY CLINIC, J401
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0001
Mailing Address - Country:US
Mailing Address - Phone:859-323-5661
Mailing Address - Fax:859-257-4999
Practice Address - Street 1:1622 SOUTH AVE W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7804
Practice Address - Country:US
Practice Address - Phone:406-543-9700
Practice Address - Fax:406-549-8109
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174401103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist