=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255463303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. LISA MARKS MAHON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 826 ADAMS ST.
-----------------------------------------------------
City | PORT TOWNSEND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98368-5506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-385-7760
-----------------------------------------------------
Fax | 360-385-6387
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 1001
-----------------------------------------------------
City | PORT TOWNSEND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98368-0008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-385-7760
-----------------------------------------------------
Fax | 360-385-6387
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LH00004582
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------