Healthcare Provider Details

I. General information

NPI: 1770120933
Provider Name (Legal Business Name): DR LISA E-THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3539 DOUGLAS DR N
MINNEAPOLIS MN
55422-2415
US

IV. Provider business mailing address

3539 DOUGLAS DR N
MINNEAPOLIS MN
55422-2415
US

V. Phone/Fax

Practice location:
  • Phone: 612-642-1355
  • Fax: 612-756-7059
Mailing address:
  • Phone: 612-642-1355
  • Fax: 612-756-7059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. LISA EILEEN LOVELACE
Title or Position: OWNER, CLINICAL PSYCHOLOGY
Credential: PSYD
Phone: 612-642-1355