Provider Demographics
NPI:1699862342
Name:STEPHEN, LISA M (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:STEPHEN
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 302
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:VT
Mailing Address - Zip Code:05465-0302
Mailing Address - Country:US
Mailing Address - Phone:802-355-9299
Mailing Address - Fax:802-419-3399
Practice Address - Street 1:145 PINE HAVEN SHORES RD STE 2294
Practice Address - Street 2:
Practice Address - City:SHELBURNE
Practice Address - State:VT
Practice Address - Zip Code:05482-7703
Practice Address - Country:US
Practice Address - Phone:802-876-1100
Practice Address - Fax:802-876-1101
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048-0000778103T00000X, 103TC1900X, 103TC2200X, 103TF0000X
VT0480000778103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT113769OtherTEAMSTERS BENEFIT HEALTH
VT189876000OtherMAGELLEN
VT87726OtherUNITED BEHAVIORAL HEALTH
VT1011334Medicaid
VT2060312OtherCIGNA BEHAVIORAL HEALTH
VT362-58036OtherBLUE CROSS/BLUE SHIELD
VT415801OtherMVP HEALTHCARE