Healthcare Provider Details

I. General information

NPI: 1790802304
Provider Name (Legal Business Name): LISA MARIE LUCY LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3171 N MERIDIAN ST
INDIANAPOLIS IN
46208-4784
US

IV. Provider business mailing address

PO BOX 242
LEBANON IN
46052-0242
US

V. Phone/Fax

Practice location:
  • Phone: 317-544-3520
  • Fax:
Mailing address:
  • Phone: 317-544-3520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001724A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number47864
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001237A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: