Healthcare Provider Details

I. General information

NPI: 1083475073
Provider Name (Legal Business Name): LISA LYNN PORTER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA L ROLAND

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2748 N NATIONAL AVE
SPRINGFIELD MO
65803-4304
US

IV. Provider business mailing address

PO BOX 844715
KANSAS CITY MO
64184-4715
US

V. Phone/Fax

Practice location:
  • Phone: 417-761-5000
  • Fax: 417-761-5065
Mailing address:
  • Phone: 417-761-5214
  • Fax: 417-761-5065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2025044493
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: