Provider Demographics
NPI:1316969157
Name:SEABRIDGE, LISA ANN (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:SEABRIDGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:BURLISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:110 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-4527
Mailing Address - Country:US
Mailing Address - Phone:580-749-5056
Mailing Address - Fax:580-215-5765
Practice Address - Street 1:110 N 4TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601
Practice Address - Country:US
Practice Address - Phone:580-749-5056
Practice Address - Fax:580-215-5765
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2155104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100716570AMedicaid