Healthcare Provider Details

I. General information

NPI: 1790286698
Provider Name (Legal Business Name): LISA WALTRIP LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19515 BRUNE PKWY
WARRENTON MO
63383-6505
US

IV. Provider business mailing address

1800 COMMUNITY
CLINTON MO
64735-8804
US

V. Phone/Fax

Practice location:
  • Phone: 636-456-1500
  • Fax:
Mailing address:
  • Phone: 660-885-8183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2017041096
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: