Provider Demographics
NPI:1720314909
Name:NIPPOLDT-BACA, LISA JOAN (PSYD, LP, ABPP)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:JOAN
Last Name:NIPPOLDT-BACA
Suffix:
Gender:F
Credentials:PSYD, LP, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1937 WOODLANE DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-764-8480
Mailing Address - Fax:651-471-9253
Practice Address - Street 1:1937 WOODLANE DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-764-8480
Practice Address - Fax:651-471-9253
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP5271103TC0700X, 103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist