Healthcare Provider Details

I. General information

NPI: 1275222077
Provider Name (Legal Business Name): MARYBETH LISSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 REDTAIL HAWK DR
ESTES PARK CO
80517-9780
US

IV. Provider business mailing address

4856 INNOVATION DR STE B
FORT COLLINS CO
80525-5540
US

V. Phone/Fax

Practice location:
  • Phone: 970-586-9105
  • Fax:
Mailing address:
  • Phone: 970-494-4200
  • Fax: 970-613-4475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC.0020629
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC.0020629
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: