Provider Demographics
NPI:1346676897
Name:KELLER SALVAGGIO, LISA JOYCE (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:JOYCE
Last Name:KELLER SALVAGGIO
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:JOYCE
Other - Last Name:KELLER SALVAGGIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 LABREE AVE S
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2819
Practice Address - Country:US
Practice Address - Phone:218-683-4349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2024-11-04
Deactivation Date:2023-09-07
Deactivation Code:
Reactivation Date:2023-09-21
Provider Licenses
StateLicense IDTaxonomies
MNLP6349103T00000X, 103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400917182OtherENROLLMENT PART B