Provider Demographics
NPI:1487316956
Name:BIRNBAUM, LISA RAE (EDS)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:RAE
Last Name:BIRNBAUM
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6914
Mailing Address - Country:US
Mailing Address - Phone:406-370-1771
Mailing Address - Fax:
Practice Address - Street 1:325 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6914
Practice Address - Country:US
Practice Address - Phone:406-370-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT72601103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool