Provider Demographics
NPI:1851560445
Name:WURZELBACHER, LISA MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:WURZELBACHER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7175 SW BEVELAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8665
Mailing Address - Country:US
Mailing Address - Phone:503-899-2157
Mailing Address - Fax:
Practice Address - Street 1:7175 SW BEVELAND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8665
Practice Address - Country:US
Practice Address - Phone:503-899-2157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2319103TC0700X
OH5203103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical