MEDICARE: MS. LISA MARIE DESLAURIERS

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

General Provider Information

NPI Number	:	1699490474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA MARIE DESLAURIERS

Provider Business Mailing Address
First Line	:	2245 PRINCETON AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1159
Country	:	US
Telephone Number	:	651-263-2144
Fax Number	:

Provider Business Practice Location Address
First Line	:	2245 PRINCETON AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1159
Country	:	US
Telephone Number	:	651-263-2144
Fax Number	:

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

Provider Enumeration Date	:	10/05/2022
Last Update Date	:	10/05/2022

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