Healthcare Provider Details

I. General information

NPI: 1699862342
Provider Name (Legal Business Name): LISA M. STEPHEN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 04/05/2025
Certification Date: 04/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 PINE HAVEN SHORES RD STE 2294
SHELBURNE VT
05482-7703
US

IV. Provider business mailing address

PO BOX 302
JERICHO VT
05465-0302
US

V. Phone/Fax

Practice location:
  • Phone: 802-876-1100
  • Fax: 802-876-1101
Mailing address:
  • Phone: 802-355-9299
  • Fax: 802-419-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number048-0000778
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number048-0000778
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number048-0000778
License Number StateVT
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number048-0000778
License Number StateVT
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0480000778
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: