MEDICARE: DR. LISA KRISTINE SAMUEL PH.D, LAC, MAC, ICGC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	ACD.0002511	CO

General Provider Information

NPI Number	:	1013848977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA KRISTINE SAMUEL PH.D, LAC, MAC, ICGC

Provider Business Mailing Address
First Line	:	2355 HIGH LONESOME TRL
Second Line	:
City	:	LAFAYETTE
State	:	CO
Zip	:	80026-9397
Country	:	US
Telephone Number	:	303-827-1056
Fax Number	:

Provider Business Practice Location Address
First Line	:	2355 HIGH LONESOME TRL
Second Line	:
City	:	LAFAYETTE
State	:	CO
Zip	:	80026-9397
Country	:	US
Telephone Number	:	303-827-1056
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2026
Last Update Date	:	05/28/2026

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