Provider Demographics
NPI:1972058907
Name:CLAIR, LISA (MED)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CLAIR
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8940 LINDEN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-8930
Mailing Address - Country:US
Mailing Address - Phone:419-467-7587
Mailing Address - Fax:
Practice Address - Street 1:8940 LINDEN LAKE RD
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-8930
Practice Address - Country:US
Practice Address - Phone:419-467-7587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP561103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool