MEDICARE: LISA REPAAL

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	103TS0200X	School Psychologist	1356579	IN

General Provider Information

NPI Number	:	1750114955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA REPAAL

Provider Business Mailing Address
First Line	:	13119 COLDWATER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9631
Country	:	US
Telephone Number	:	260-637-3155
Fax Number	:

Provider Business Practice Location Address
First Line	:	13119 COLDWATER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9631
Country	:	US
Telephone Number	:	317-777-7536
Fax Number	:

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

Provider Enumeration Date	:	08/22/2024
Last Update Date	:	08/22/2024

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Directions to “ LISA REPAAL ” Practice Location

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