Provider Demographics
NPI:1487621306
Name:LABICHE, LISE AMY
Entity type:Individual
Prefix:
First Name:LISE
Middle Name:AMY
Last Name:LABICHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISE
Other - Middle Name:AMY
Other - Last Name:LABICHE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 678186
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8186
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:3535 S INTERSTATE 35 E
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6850
Practice Address - Country:US
Practice Address - Phone:940-384-3535
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23562084N0400X
IL036-1625082084N0400X
TXK98302084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158290002Medicaid
WI100221656Medicaid
TXK9830OtherTEXAS MEDICAL LICENSE
TXP00477936OtherRR MEDICARE
TXK9830OtherTEXAS MEDICAL LICENSE