Healthcare Provider Details

I. General information

NPI: 1134158751
Provider Name (Legal Business Name): LISA MARIE COLLINGWOOD PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8204 ELMBROOK DR SUITE 360
DALLAS TX
75247-4067
US

IV. Provider business mailing address

1337 S CESAR E CHAVEZ DR
MILWAUKEE WI
53204-2712
US

V. Phone/Fax

Practice location:
  • Phone: 214-219-0780
  • Fax: 214-219-0782
Mailing address:
  • Phone: 414-897-5511
  • Fax: 414-385-7552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3031
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: