Provider Demographics
NPI:1699965137
Name:RANDERSON, LISA (LPC, SAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RANDERSON
Suffix:
Gender:F
Credentials:LPC, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 NICOLET BLVD
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2756
Mailing Address - Country:US
Mailing Address - Phone:920-915-3735
Mailing Address - Fax:920-738-9901
Practice Address - Street 1:301 NICOLET BLVD
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2756
Practice Address - Country:US
Practice Address - Phone:920-915-3735
Practice Address - Fax:920-738-9901
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15687-131101YA0400X
WI4263-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)