Healthcare Provider Details

I. General information

NPI: 1235166539
Provider Name (Legal Business Name): MRS. LISA REISDORF BISHOP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA BISHOP LMHC

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 SOUTHPARK BLVD
ST AUGUSTINE FL
32086-4101
US

IV. Provider business mailing address

508 12TH ST
ST AUGUSTINE FL
32084-1462
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-7597
  • Fax:
Mailing address:
  • Phone: 904-687-0581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 7777
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: