Healthcare Provider Details

I. General information

NPI: 1013725233
Provider Name (Legal Business Name): LISA EZZELL LMFTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2024
Last Update Date: 12/19/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SPRING LAKE COUNSELING 104 LAKE AVENUE
SPRING LAKE NC
28390
US

IV. Provider business mailing address

5604 ROYAL PINES CIR
WADE NC
28395-9088
US

V. Phone/Fax

Practice location:
  • Phone: 910-920-1050
  • Fax: 910-920-1051
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number20045A
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: