Provider Demographics
NPI:1588722193
Name:DAHLGREN, LISA ANN (PH D)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:DAHLGREN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:12400 OLIVE BLVD
Mailing Address - Street 2:STE 205
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6431
Mailing Address - Country:US
Mailing Address - Phone:636-394-6210
Mailing Address - Fax:314-275-2301
Practice Address - Street 1:12400 OLIVE BLVD
Practice Address - Street 2:STE 205
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6431
Practice Address - Country:US
Practice Address - Phone:636-394-6210
Practice Address - Fax:314-275-2301
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO01546103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO28825OtherANTHEM BLUE CROSS BS