Healthcare Provider Details

I. General information

NPI: 1992897227
Provider Name (Legal Business Name): JUDETH L THORNDIKE LISAC, BSBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 S OCOTILLO AVE
BENSON AZ
85602
US

IV. Provider business mailing address

155 CALLE PORTAL
SIERRA VISTA AZ
85635-2900
US

V. Phone/Fax

Practice location:
  • Phone: 520-586-4040
  • Fax: 520-586-4423
Mailing address:
  • Phone: 520-459-3012
  • Fax: 520-515-8663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC1602
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: