Healthcare Provider Details

I. General information

NPI: 1629642137
Provider Name (Legal Business Name): LISA YEAGER LCAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 WATERFALL DR
ELKHART IN
46516-3668
US

IV. Provider business mailing address

240 WATERFALL DR
ELKHART IN
46516-3668
US

V. Phone/Fax

Practice location:
  • Phone: 574-301-7300
  • Fax: 574-301-7303
Mailing address:
  • Phone: 574-301-7300
  • Fax: 574-301-7303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001647A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: