Provider Demographics
NPI:1003010711
Name:EVANICH, LISA MARIE (MA, LPC, CACIII)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:EVANICH
Suffix:
Gender:F
Credentials:MA, LPC, CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 28 RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-4759
Mailing Address - Country:US
Mailing Address - Phone:970-260-3321
Mailing Address - Fax:
Practice Address - Street 1:360 28 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-4759
Practice Address - Country:US
Practice Address - Phone:970-260-3321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6457101YA0400X
CO3092101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health