Healthcare Provider Details

I. General information

NPI: 1053685313
Provider Name (Legal Business Name): GLORIA HARRIS LISAC, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 W PARK ST
PHOENIX AZ
85041-5477
US

IV. Provider business mailing address

2227 W PARK ST
PHOENIX AZ
85041-5477
US

V. Phone/Fax

Practice location:
  • Phone: 520-280-8009
  • Fax: 480-393-7598
Mailing address:
  • Phone: 520-280-8009
  • Fax: 480-393-7598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-15138
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: