Healthcare Provider Details

I. General information

NPI: 1275903288
Provider Name (Legal Business Name): LISA FADORSEN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 03/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 26TH AVE E
BRADENTON FL
34208-7753
US

IV. Provider business mailing address

PO BOX 9478
BRADENTON FL
34206-9478
US

V. Phone/Fax

Practice location:
  • Phone: 941-782-4600
  • Fax: 941-782-4601
Mailing address:
  • Phone: 941-782-4299
  • Fax: 941-782-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE1200017
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPMH1252
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1198
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH15099
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: