Healthcare Provider Details

I. General information

NPI: 1134672975
Provider Name (Legal Business Name): LISA T BARGENDER LCSW, CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 BROADWAY ST
BARABOO WI
53913-2183
US

IV. Provider business mailing address

2514 LENNON ST
PORTAGE WI
53901-1125
US

V. Phone/Fax

Practice location:
  • Phone: 608-355-4200
  • Fax: 608-355-4299
Mailing address:
  • Phone: 608-843-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18096
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number130020-121
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8967
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: