Healthcare Provider Details

I. General information

NPI: 1093455396
Provider Name (Legal Business Name): PATRICK ANDERSON LISAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 N 30TH AVE
PHOENIX AZ
85017-4607
US

IV. Provider business mailing address

3930 N 30TH AVE
PHOENIX AZ
85017-4607
US

V. Phone/Fax

Practice location:
  • Phone: 623-322-6143
  • Fax: 480-781-4566
Mailing address:
  • Phone: 623-322-6143
  • Fax: 480-781-4566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15174
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: