Provider Demographics
NPI:1427538644
Name:VAIT, LISA MARIE (LADC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:VAIT
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19247 COUNTY ROAD 44
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55320-1535
Mailing Address - Country:US
Mailing Address - Phone:320-237-3413
Mailing Address - Fax:320-558-2807
Practice Address - Street 1:19247 COUNTY ROAD 44
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:MN
Practice Address - Zip Code:55320-1535
Practice Address - Country:US
Practice Address - Phone:320-237-3413
Practice Address - Fax:320-558-2807
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303952101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN303952OtherALCOHOL AND DRUG COUNSELOR LICENSE NUMBER
MNM983181556620OtherDRIVERS LICENSE