Healthcare Provider Details

I. General information

NPI: 1225435274
Provider Name (Legal Business Name): LISA M NACKERS PHD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4602 EASTPARK BLVD
MADISON WI
53718-2002
US

IV. Provider business mailing address

4602 EASTPARK BLVD MAIL CODE AC05
MADISON WI
53718-2002
US

V. Phone/Fax

Practice location:
  • Phone: 608-265-7090
  • Fax: 608-234-6695
Mailing address:
  • Phone: 608-265-7090
  • Fax: 608-234-6695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3259
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-008908
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: