Healthcare Provider Details

I. General information

NPI: 1225903099
Provider Name (Legal Business Name): LISA THAI MFTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2025
Last Update Date: 10/09/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 E 18TH AVE STE 4
EUGENE OR
97401-4081
US

IV. Provider business mailing address

74 E 18TH AVE STE 4
EUGENE OR
97401-4081
US

V. Phone/Fax

Practice location:
  • Phone: 541-833-0205
  • Fax: 541-833-4033
Mailing address:
  • Phone: 541-321-6137
  • Fax: 541-833-4033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR12042
License Number StateOR

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: