Provider Demographics
NPI:1407377245
Name:LISA L. MIKESELL LLC
Entity type:Organization
Organization Name:LISA L. MIKESELL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MIKESELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW CACIII
Authorized Official - Phone:303-776-1117
Mailing Address - Street 1:1300 GAY CIR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1876
Mailing Address - Country:US
Mailing Address - Phone:303-249-7910
Mailing Address - Fax:303-485-2323
Practice Address - Street 1:1801 SUNSET PL STE A
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6575
Practice Address - Country:US
Practice Address - Phone:303-776-1117
Practice Address - Fax:303-485-2323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-02
Last Update Date:2017-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO992369261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health