Healthcare Provider Details

I. General information

NPI: 1316712151
Provider Name (Legal Business Name): LISSETTE D FREDERICK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5995 IRIS PKWY
FREDERICK CO
80504-6412
US

IV. Provider business mailing address

203 S ROLLIE AVE
FORT LUPTON CO
80621-1508
US

V. Phone/Fax

Practice location:
  • Phone: 303-697-2583
  • Fax: 303-833-6515
Mailing address:
  • Phone: 303-892-6401
  • Fax: 303-286-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0019840
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: