Provider Demographics
NPI:1316712151
Name:FREDERICK, LISSETTE D (LPC)
Entity type:Individual
Prefix:
First Name:LISSETTE
Middle Name:D
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-892-6401
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:5995 IRIS PKWY
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:CO
Practice Address - Zip Code:80504-6412
Practice Address - Country:US
Practice Address - Phone:303-697-2583
Practice Address - Fax:303-833-6515
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0019840101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional