Provider Demographics
NPI:1528666476
Name:OSBORNE, LISSA MARIE (AA)
Entity type:Individual
Prefix:MRS
First Name:LISSA
Middle Name:MARIE
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:LISSA
Other - Middle Name:MARIE
Other - Last Name:HERRICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:708 E ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4747
Mailing Address - Country:US
Mailing Address - Phone:360-388-8090
Mailing Address - Fax:
Practice Address - Street 1:708 E ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4747
Practice Address - Country:US
Practice Address - Phone:360-388-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61026839101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor