Provider Demographics
NPI:1417386764
Name:PERLOCK, LISA (LPCC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PERLOCK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14300 NICOLLET CT
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-4501
Mailing Address - Country:US
Mailing Address - Phone:952-435-8814
Mailing Address - Fax:
Practice Address - Street 1:14300 NICOLLET CT STE 130
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-3422
Practice Address - Country:US
Practice Address - Phone:952-435-8814
Practice Address - Fax:952-435-7705
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00660101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional